POSTED FEBRUARY 17, 2016
DEAR DOCTOR K:
My back is always sore. A friend suggested that massage therapy might help. Massages are expensive, so I want to make sure there’s some evidence behind this. Is there?
Massage used to be considered an indulgence. But it’s now recognized as a legitimate therapy for some painful conditions — including back pain.
Therapeutic massage may relieve pain in several ways. It may relax painful muscles, tendons and joints, or relieve stress and anxiety. It may even change the way the brain processes pain signals.
Many types of massage are available in the United States, with Swedish massage being the most common. It involves long, gliding strokes and kneading of the major muscle groups, as well as friction, gentle rhythmic slapping and vibration. Other massage techniques include deep-tissue, pressure-point, Thai and neuromuscular massage. (I’ve put a table describing different types of massage, and what they involve, below.)
Types of massage
There’s more to massage or “body work” than kneading and squeezing of tight muscles. Some approaches sprang from traditional medicine, while others were developed more recently. Here are some common options.
Type How it works
Acupressure (shiatsu) Deep finger pressure applied along “energy channels” in the body called meridians.
Cranial-sacral therapy Claims to use light touch to adjust the balance and flow of cerebrospinal fluid.
Deep-tissue massage Aggressive massage to relieve severe tension in the muscle and the connective tissues.
Neuromuscular therapy Massage to relieve acute or chronic pain.
Myofascial release Massage intended to release tension in the connective tissue surrounding the muscles.
Sports massage Massage to help athletes prepare for and recover from sports activities.
Swedish massage Long strokes with gentle or firm pressure as well as kneading.
Source: American Massage Therapy Association: health.harvard.edu/bmt
Massage therapy can also involve varying degrees of pressure. Massage doesn’t have to be painful to be therapeutic, so be sure to tell your therapist what type of touch you prefer (light touch, firm pressure, hard pressure).
Massage should not be the only treatment you use for back pain. Instead, use massage in addition to standard care. That includes taking anti-inflammatory pain relievers, staying as active as possible, getting physical therapy and giving your body time to heal. When added to the mix, massage can reduce pain and speed your return to normal activities.
There hasn’t been enough research to say for certain what type of massage is best for back pain. We also don’t know the optimal “dose” and frequency of treatment.
Talk to people you know to get a recommendation. Good practitioners get good results and generate positive referrals. Find out if a medical center in your area has an alternative or integrative medicine program. Such programs typically offer massage by qualified practitioners: people licensed to practice in your state, and certified by a national organization such as the American Massage Therapy Association (www.amtamassage.org).
When I was just beginning medical practice, I learned a valuable lesson. A woman in her mid-80s told me that she had trouble sleeping. I told her about the various ways to improve her “sleep hygiene,” such as going to bed and getting up at the same time each day, not watching TV while in bed, etc.
When I saw her a few months later, she said a massage therapist had cured her sleep problem — and implied that my advice hadn’t done much good. What was keeping her up (as I would have known, had I asked her more questions about her sleep problem) was chronic back pain. That was resolved with massage — and she slept like a baby.
FEBRUARY 16, 2016
“I love a good massage — I don’t need to be wrapped in herbs like a salmon filet but I do love a massage!” – Jason Bateman
By Jordan Leasure, BA, DC, CCWP
Massages are appropriate for any occasion, or no occasion at all! The Mayo Clinic sites studies of the benefits of massage demonstrate that it is an effective treatment for reducing stress, pain and muscle tension. While more research is needed to confirm this, some studies have found massage may also be helpful for everything from anxiety and depression to digestive disorders.
Choose the massage appropriate for you based on your goals of treatment. Following are some some different options with some better for stress relief while others are effective in restoring overworked muscles. Be aware that depending on where you go for a massage, it may involve oil, lotion, aromatherapy, rocks and even hot bamboo sticks.
Swedish Massage–Swedish massage is often referred to as relaxation massage. It consists of long, flowing strokes, often in the direction of the heart. Therapists use massage lotion to minimize friction —or pulling on the tissue— and may incorporate circular movements and kneading of the muscles. This is very effective for releasing tension and stress despite typically held in a spa.
Deep Tissue Massage–This is targeted at muscles that have been strained or are related to chronic pain or posture problems. The therapist targets deep layers of muscles and connective tissue by using short strokes and intense pressure. It’s not uncommon for clients to feel sore for several days after such a session, but the benefits can be worth it. Therapists at chiropractic offices are extensively trained to target the muscles that are contributing to your diagnosis to help resolution take place as quickly as possible.
Trigger Point Therapy–Trigger point therapy is similar to deep tissue massage in that a specific area of the body is focused on and may cause some discomfort during the procedure. A trigger point is a tight area in a muscle that may refer pain to other areas. For example: a trigger point in the neck can cause headaches while one in the upper back can cause chest pain. While not a pleasurable experience, the results can be system wide. With a little equipment —such as a lacrosse ball or a theracane— this is a therapy that you could provide yourself.
Sports Massage–Consider this an all of the above treatment. It is the best of all worlds — stretching of over worked muscles, trigger point eradication, cross friction pressure, and even flowing strokes to conclude. A sports massage can help not only keep you in the game but recuperate from the last competition.
Offered in work environments, clinics, malls, airports, and of course spas, the art of massage has taken the world by storm. But did you know that research shows massages can literally de-stress you and make you look younger? Regarded as the "number-one stress reliever" by celebrity massage therapist Dr. Dot, studies throughout the years have found massage therapy to reduce heart rate, cortisone levels and blood pressure while also bettering sleep quality and reducing migraine headaches.
In a study conducted by Tiffany Field, et al., the results showed a bevy of positive effects of massage therapy including decreased levels of cortisol and increased levels of serotonin and dopamine, suggesting relaxation in the brain and better sleep quality. The Touch Research Institute at the University of Miami School of Medicine studied the impact of massage therapy on the body, as well, and resulted in stellar findings. Analyses of individuals who were given a massage two times per week for five weeks revealed an increase in frontal delta wave power (suggesting relaxation), decreased frontal alpha and beta wave power (suggesting enhanced alertness), increased speed and accuracy on math computations, lowered anxiety levels and decreased stress scores.
According to Kristi Dickinson, director of Spa and Fitness at Rancho Valencia Resort & Spa, managing stress is critical to maintaining a youthful appearance for several reasons. “When we are stressed, our bodies initiate an inflammatory response. The less time we spend in the parasympathetic state, the less time we have for cellular regeneration and proper digestion. When our digestion is sluggish, we fail to absorb and utilize nutrients needed for essential life processes and that healthy skin glow, lush hair and beautiful nails."
While stress seems bad enough on its own, it also ages us—and not only emotionally—by shortening our telomeres (stretches of DNA at the ends of chromosomes, which allow cells to divide), which, according to Dickinson, is associated with aging and cancer. Even the anticipation of stress has been found to accelerate cellular aging, resulting in an older appearance. Additionally, individuals with high levels of cortisol almost always look older than they really are. An article in the Los Angeles Times explains that researchers estimate that each micromole per liter of cortisol ages an individual by approximately half a year.
For an enhanced de-stressing experience, look for a spa that offers color therapy, a treatment with a range of benefits from relaxing muscles and stimulating nerve transmission to stimulating the production of collagen. EAU Spa in Palm Beach allows you to pick the color you would like to surround yourself with while receiving a massage or any treatment to enhance your experience. Here’s a quick guide to color therapy before you book an appointment:
Blue: This peaceful hue has been found to calm restlessness and pain while instilling a truly tranquil mood.
Red: Red has been shown to restore depleted energy while also jumpstarting the nervous and circulatory systems.
Orange: Said to eliminate fat, orange can also be used to relieve nervous tension and arthritis with its vitalizing radiance that has also been found to calm fear.
Yellow: A warm, positive color with a purifying effect, yellow has been used to strengthen the nervous system, assist metabolism and stimulate skin.
Green: Cooling and balancing, green helps reduce any swelling or inflammation of joints while simultaneously calming the body.
So what can we do to stop aging in its tracks? Do your best to book a massage appointment at least once a month to keep stress levels low. Turns out there truly is more to a spa day.
The antidote to a stressful day, relationship woes, or ailments could lie right at our fingertips. An affectionate touch is an intimate act that could channel feel-good energy through our bodies, and help build a connection between two people. Massages can be a form of intimacy that benefits our wellbeing, but are we being touched enough?
In a new Touch Initiative survey, a partnership between K-Y and The Kinsey Institute, researchers revealed there is a touch crisis in America. Close to 90 percent of men and women in committed relationships rated regular or intimate touch as very or extremely important to building intimacy, and people prefer to be touched by their partner rather than talking without touching. Yet over a third of people say they’re not touched enough in their romantic relationships.
Dr. Justin Garcia, a research scientist at The Kinsey Institute, says the disparity between couples who long to be touched and those who actually are could be attributed to a common shift. Between 18 and 26 months into a relationship, some couples go through a transition from passionate love, which centers on attention, obsessive thought, and intense cravings for love, to companion love.
"We move somewhat adaptively into companion love. That shift is important when we want to stay with someone for a long time," Garcia told Medical Daily. “When we do that shift, we do less touch. You get less forms of communication and intimacy.”
This is why he believes massage and touch are integral in maintaining relationships and sexual satisfaction. The best way to think about touch is that it's nonverbal communication, according to Garcia. A small touch on someone’s arm, their hand, or their back as they walk is a really great way to build a connection between two people.
Dr. Laura Berman, a world renowned sex and relationship educator and therapist, suggests the more time spent touching and kissing, as part of foreplay, the better. For example, if the man feels he’s reaching out with tenderness, love, and affection, then the woman feels closer to him, according to Berman. The closer a woman feels to him emotionally, the more inspired she is to have sex with him.
This doesn’t just apply to sex. Touch also has the power to boost our health. “The more cuddling and physical connection, the better for your health, including stress levels and the immune system,” Berman told Medical Daily.
This Valentine’s Day, say it with a touch, and give your significant other a massage to reap its surprising benefits, from boosting immunity to improving sleep.
Getting a massage not only helps us relax, but also gives our immune system a boost. Receiving a 45-minute massage has been found to increase the number of lymphocytes, white blood cells that help defend the body from disease, according to a 2010 study. Other physical changes included: Lower levels of cytokines, molecules that play a role in inflammation; a decrease in the stress hormone cortisol; and a decrease in vasopression, a hormone that plays a role in aggressive behavior. One session of massage therapy is enough to produce measurable changes in the body’s immune and endocrine response.
About half of Americans say that poor or insufficient sleep has affected their daily activities at least once in the past seven days. A bad night’s sleep can be remedied with massage therapy, according to the National Institutes of Health. Several studies have found that getting a massage reduced fatigue and improved sleep in infants, children, adults, and the elderly, including those with psychiatric disorders, cancer, and heart disease, among many others. Most studies credit it to massages increasing delta waves, brain waves connected to deep sleep, which would explain why it’s easier to drift off on a massage table.
Manage Anxiety and Depression
It’s easy to feel anxious or fall into depression when we’re going through tough times. However, a massage can soothe these feelings by reducing cortisol levels. Previous research has found adults asked to relax in a massage chair for 15 minutes, two times per week for five weeks, experienced an increase in frontal delta waves (slow, loud brainwaves that suspend external awareness and are a source of empathy), which promoted feelings of relaxation. Meanwhile, frontal alpha brainwaves and the strength of beta waves (present in the brain when we’re alert) decreased. This helped adults fall into deep relaxation and decrease their anxiety.
A similar study found that depressed adolescent mothers who received ten, 30-minute sessions of massage therapy over a five-week period had less anxious behavior and reduced heart rates and cortisol levels.
Considering all of its mental and physical benefits, it’s little surprise that the desire for touch doesn’t vary by gender, age, sexual orientation, or socioeconomic status, according to Dr. Garcia: “It’s fundamentally human.” A massage is one of the most simple and effective ways to be touched and feel a sense of intimacy with someone, especially if you're single.
Ian McCafferty, November 25, 2015
Fibromyalgia (FM) affects more than 3 million Americans every year. This chronic condition causes widespread muscle pain and increased sensitivity to stimuli that often lead to pain and difficulty sleeping, among other symptoms. Treatment is varied, but some of the current research indicates that massage therapy can be effective in helping to relieve some of the discomfort.
But FM is a complex disorder, and so working with clients who have FM is no different than working with clients with other chronic or pre-existing health conditions: you need to have a better-than-average understanding of how the condition affects the client, as well as when massage therapy can be helpful. Following, you will find information on what recent research is saying about FM and the role massage therapy can play in helping people better deal with some of the symptoms.
What is Fibromyalgia?
Fibromyalgia is a disorder characterized by widespread muscle pain and tenderness. Other common symptoms associated with FM include fatigue, tension headaches, cognitive difficulties and irritable bowel syndrome.
Interestingly, more of the research on FM is starting to suggest that the condition is actually a central nervous system disorder, even though muscle pain is one of its primary symptoms. More specifically, evidence points to the idea that FM is a disorder of central nervous system pain processing pathways instead of a primary auto-immune disorder of the peripheral tissue, as once believed.1 “There were studies that showed the association between stressors and FM,” explains Stephen Perle, Professor of Clinical Sciences at Bridgeport University. “For example, fMRI has shown that people with FM, when exposed to non-painful stimuli, have activation of the brain in areas that are normally activated only by painful stimuli.”
Accordingly, central nervous system involvement may explain why people with FM are often hypersensitive to all sorts of stimuli, not just mechanical pressure or touch. Dr. Michael Schneider, Associate Professor at the University of Pittsburgh and the author of multiple studies on FM, provides more insight: “The classic fibromyalgia patient just isn’t tender to the touch and can’t submit to mechanical pressure,” he explains. “They’re sensitive to light, sound, [may have] multiple food allergies, multiple chemical sensitivities, and they don’t tolerate heat and cold real well.”
Who Develops Fibromyalgia?
The short answer to this question is that women are much more likely than men to develop fibromyalgia—but it is more complicated than that. The likelihood that someone will develop FM isn’t well-known, but there are two variables that seem to be related: genetics and personal trauma. Genetics is fairly straightforward. FM tends to run in families.
Trauma, however, is a bit more complex. There seems to be a link between FM and post-traumatic stress disorder, though one does not necessarily cause the other. A 2001 study of 600 participants with FM showed “an extremely high prevalence of past emotional, physical and/or sexual trauma associated with the onset of FM symptoms.”2 Schneider’s review of the FM research literature suggests that the connection between personal trauma and FM may be that trauma often causes a person’s limbic system to go into overdrive, contributing to the central nervous system hypersensitivity.1 Remember, not everyone with FM is going to have experienced trauma, but you should keep the possibility in mind when working with clients with this condition. “There’s a high association with trauma, and people need to be aware of that when they’re treating these patients,” says Schneider.
Treatment for Fibromyalgia
There is no one pill or treatment that cures fibromyalgia or even relieves all of the symptoms, so many people with FM deal with this condition using multiple approaches. Most will likely be taking medication prescribed by their primary care physician, so be sure you do a thorough intake and understand how any medication they are taking may affect the massage therapy session. Remember that for these clients, self-care is crucial to being able to better control the major symptoms of FM. Therefore, focus on how massage therapy can help them reduce stress, for example, or get better sleep.
Along with massage therapy, these clients may be using other complementary approaches, such as acupuncture and yoga. When combined, Schneider sees real benefit from both traditional and complementary treatment. “These patients are best treated with a team approach,” he says.
Massage Therapy and Fibromyalgia
Of all the alternative therapies available, more and more research is showing that massage therapy provides real benefits to people dealing with a number of health conditions, including fibromyalgia. A study in 2011 showed that massage therapy caused reductions in sensitivity to pain at tender points in patients with FM, as well as lowering anxiety levels and increasing quality of sleep.3 Another study from 2014, which systematically reviewed nine other studies about massage therapy and FM, found that massage therapy had immediate beneficial effects on improving pain, anxiety and depression in patients with FM.4
According to this same study, massage therapy is particularly effective when it is administered to soft and connective tissues because this improves muscle flexibility, as well as modulating local blood and lymph circulation.4
There is not one specific technique that is more effective with FM than others, although myofascial release has been shown to be somewhat helpful.5 “To new massage therapists who would like to work with FM clients, I would tell them to fill their proverbial tool box with as many techniques as they can,” says Joseph Swinski, a massage therapist from Rhode Island who regularly works with clients with chronic conditions such as FM. “When working with the FM population, it is not one size fits all.”
For many clients, using the right amount of pressure is going to be imperative, so it is important to clearly communicate with the client both before and during the session and adjust when necessary. Remember that deep pressure will likely be too much for these clients. “If they’re hypersensitive, then the idea is you’re going to have to go really light with them and kind of coddle that client and be a little more gentle with them,” says Schneider. This idea holds true for all aspects of the massage session. “Speak in a lower voice to them, and that person’s going to like the dim room with some nice relaxing music,” he adds.
Flexibility is also a key ingredient to success when working with people with FM. “The most important thing I could hope to impress on a new massage therapist working with a client with FM is to be patient, not in a hurry and as observant as possible during the actual session,” says Erika Crisafulli, a massage therapist with the Texas Health Harris Methodist Hospital in Fort Worth. “Be compassionate. We all know what it is like to deal with physical ailments that we cannot get a hold of on our own.” Crisafulli knows this better than most, as she herself has had to deal with symptoms of FM. “Trying to control the symptoms so you can still live a full life is challenging, but not impossible if you are willing to help yourself,” she says. “It is so important to practice what you preach. If I don’t take care of myself, how in the world can I take care of my clients, something I love to do so much?”
Checking in with a client after a massage therapy session is also a good idea, and that sometimes means following up a few days later. “You may need to change your approach to massage after the first visit,” says Swinski. “This is why I contact my clients after the massage. If the results were not what we expected, I reassure them that there are other approaches that we could take in their next visit.” Again, you need to be aware that clients with FM are going to have different needs. What works for some may not work for others, so listen and be willing to adjust the massage therapy session when appropriate.
Although FM is a complex condition, research is showing there are a variety of ways massage therapy can help clients feel better. From better sleep to reduced stress, massage therapy is showing real promise in helping people better handle the symptoms of FM.
An Evidence Based Guide to Fibromyalgia for Massage Therapists | 2 CE Credits
In this online course, learn assessments, therapies and self-care exercises to help you design massage therapy programs for clients with fibromyalgia. Register now »
Does Your Client Really Have Fibromyalgia?
For many people, getting a diagnosis of fibromyalgia is a long, complicated process. Still, because FM is a complex, misunderstood condition, overdiagnosis is an emerging problem.
In a 2006 study titled Differential Diagnosis of Fibromyalgia Syndrome, Dr. Michael Schneider, Associate Professor at the University of Pittsburgh and the author of multiple studies on FM, found the condition often being used as a catchall diagnosis. “There is a problem with the current conceptual model of FM as one grandiose syndrome into which all patients with unexplained widespread pain are categorized,” the study concludes.
The complicated nature of FM diagnosis means you could encounter clients who may have been misdiagnosed. So, what does that mean for massage therapists who have clients with FM? The truth is, even if a client has been misdiagnosed, massage therapy can be effective—and massage therapists need to let the client lead.
“So the question is, is the massage helpful or not? If that client comes back next week for another massage and [says], ‘Oh, I feel great after that first massage.’ Excellent, let’s do it again,” says Schneider. “If that’s the expectation of the patient—to get some temporary relief—and they are, what’s the difference? They’re still getting relief.”
The Study Question:
Fibromyalgia affects 2 to 3 percent of the population worldwide and is a condition commonly treated by massage therapists. Although the condition is diagnosed based on self-reported muscular pain, recent evidence points to the source of the pain as originating from the nervous system, via the process of central sensitization—the abnormal amplification of pain signals in the spinal cord. Is one massage therapy approach more effective in relieving fibromyalgia symptoms of general and localized muscular pain compared to another?
This article presents the results of a pilot study conducted at Oregon Health & Sciences University in Portland, Oregon, that compared myofascial release (MFR) to Swedish massage. While Swedish massage is often used by massage therapists to address fibromyalgia symptoms, the fascia surrounding skeletal muscle tissue is highly innervated and contains fibroblasts that can regulate inflammation. The researchers hypothesized that these pain-generating characteristics of fascia might play a role in maintaining fibromyalgia symptoms, and they reasoned that a technique that specifically targets fascia, such as myofascial release, might show greater benefits in reducing symptoms compared to a more general Swedish massage. A secondary goal of this pilot study was to see whether it was possible to measure improvement in localized areas of pain in conditions that result in widespread pain and central sensitization—conditions that include fibromyalgia, low back pain and temporomandibular disorder.
The Study Methods:
The study authors recruited a convenience sample of 12 women between 21–50 years of age who had a verified diagnosis of fibromyalgia. The participants were allowed to continue any existing treatment, either pharmacological or nonpharmacological, as long as they had been on it for the previous three months and agreed to not make any changes to the existing treatment during the study period. Exclusion criteria were concurrent pain conditions such as diabetic neuropathy, cervical or lumbar disc disease, or severe depression. People who were already receiving any form of manual therapy—including massage, Rolfing, chiropractic or physical therapy—were also excluded, as were those who preferred not to be touched, or who were involved in any litigation or applying for disability. Measures were assessed at baseline, before each session and at two weeks post treatment. All participants received 90-minute sessions once a week for four consecutive weeks. Eight women received MFR and four women received Swedish massage. The method of allocation to the type of massage therapy participants received was not specified.
The primary outcome measure was the Fibromyalgia Impact Questionnaire-Revised (FIQ-R), a 21-item self-report instrument that assesses primary symptoms of fibromyalgia, physical functioning and quality of life. Higher scores indicate more severe symptoms and decreased physical functioning and quality of life. A secondary measure, the Nordic Musculoskeletal Questionnaire (NMQ), was used to measure localized pain in seven body regions: the neck, shoulders, upper and lower back, arms, and upper and lower legs. Higher scores on a 0–3 scale indicate greater pain. All outcomes were measured by a single examiner who was blind to treatment group.
The study intervention consisted of either Swedish massage applied to the back, neck, arms and legs with moderate pressure stroking, or MFR performed on the same regions, using prolonged assisted stretching applied to painful areas. Three different licensed massage therapists delivered the intervention, and each had prior experience working with people with fibromyalgia using both techniques. The therapists also had received advanced training in MFR.
There were no pre-existing demographic or baseline differences between the two groups. The majority (90 percent) had tried Swedish massage previously and 70 percent reported some immediate but short-term improvement as a result of prior massage, generally lasting a few hours. Five of the eight participants in the MFR group reported clinically significant improvement in their FIQ-R scores, compared to one participant in the Swedish massage group. NMQ scores improved in both groups, but showed consistent improvement in the neck and upper back regions for the MFR group, while no local areas of improvement were observed in the Swedish massage group.
Limitations of the study:
The sample size was small, so the study did not have sufficient statistical power to estimate an effect size or determine efficacy, and participants were not randomized to the two treatment groups. The dose of massage was relatively small when compared to other studies of massage and fibromyalgia, and the longer-term effects were not measured. The sample was also limited to only women, so the results cannot be generalized to men, minorities or severely depressed people with fibromyalgia. However, it was designed as a pilot for a larger study.
Implications for evidence-informed practice:
Previous research shows that Swedish massage can provide at least temporary relief of general pain for people living with fibromyalgia. At the same time, addressing local muscle pain is a critical therapeutic goal in working with people with fibromyalgia. The results of this study are intriguing because they suggest a possible mechanism for how MFR might reduce pain, and hold some promise for further investigation of MFR as a longer-lasting treatment for reducing localized pain and tenderness in fibromyalgia. MFR may also have potential as an intervention to address central sensitization, but this hypothesis will require more research to determine. Practitioners who frequently see patients or clients with pain conditions involving central sensitization may want to consider adding MFR to their therapeutic repertoire.
1. Michael J. Schneider, DC, PhD, David M. Brady, ND, DC, and Stephen M. Perle, DC, MS (2006) Differential diagnosis of fibromyalgia syndrome: Proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. J Manipulative Physiol Ther. 2006 Jul–Aug;29(6):493-501.
2. Walen HR, Oliver K, Groessl E, Cronan TA, Rodriguez VM. Traumatic events, health outcomes, and health care use in patients with fibromyalgia. J Musculoskelet Pain 2001;9: 19–38
3. Castro-Sánchez, A.M., Matarán-Peñarrocha, G.A., Granero-Molina, J., Aguilera-Manrique, G., Quesada-Rubio, J.M., Moreno-Lorenzo, C. (2011). Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med. 2011:561753.
4. Li Y.H., Wang F.Y., Feng C.Q., Yang X.F., Sun Y.H. (2014) Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. 2014 Feb 20;9(2):e89304. doi: 10.1371/journal.pone.0089304. eCollection 2014.
5. Castro-Sánchez, A.M., Matarán-Peñarrocha, G.A., Granero-Molina, J., Aguilera-Manrique, G., Quesada-Rubio, J.M., Moreno-Lorenzo, C. (2011). Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med. 2011:561753.