Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by anxiety, depression, sleep disturbances, fatigue, and memory issues. According to the Mayo Clinic, fibromyalgia amplifies painful sensations by affecting the way the brain processes pain signals.1 Approximately 2–5 percent of the population is affected by fibromyalgia, leading to reduced activities in daily living and work capability.2
Fibromyalgia can be difficult to diagnose and treat. Pain and fatigue are often misdiagnosed as other conditions, such as chronic fatigue syndrome, hypothyroidism, and malingering. In some individuals, the diagnosis is not made for years due to overlapping symptoms. Once diagnosed, patients typically see several health-care providers in order to determine the best treatment for their condition. Traditionally, those with fibromyalgia try various medications, undergo physical therapy, and attend pain clinics. Because of the lack of success with conventional treatment, approximately 90 percent of those with fibromyalgia seek relief through at least one form of complementary and alternative treatment such as acupuncture, chiropractic, herbal supplements, and massage therapy.3

Limitations
Yan-hui Li and a team of researchers recently published an article titled “Massage Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.”3 The authors searched 10 English and Chinese research databases for studies evaluating massage therapy for fibromyalgia. All studies included in the review met the following criteria: (1) the study was a randomized controlled trial of massage therapy for fibromyalgia, (2) study participants with fibromyalgia were diagnosed according to the American College of Rheumatology criteria, (3) massage therapy was independent of other manual therapy interventions, indicating that other therapies were not combined with massage, (4) any type of comparison group was allowed, (5) the main outcome measures included anxiety, depression, pain, and sleep disturbance, and (6) the articles were written in either English or Chinese.
Nine randomized controlled trials involving 404 subjects were ultimately included in the review. All nine clinical trials included some measurement of pain. The results of the review demonstrated that in massage therapy studies with a duration of at least five weeks, there was significant reduction of fibromyalgia pain. However, no significant reduction in pain was demonstrated in studies of less than five weeks.
Massage therapy results for anxiety and depression were similar to those for pain. Both anxiety and depression were significantly improved in massage therapy studies that were at least five weeks in duration, with no significant reduction in anxiety or depression in studies of less than five weeks.
Overall, the clinical trials as a group did not show improvement in sleep disturbances in patients with fibromyalgia who received massage therapy, regardless of the duration. However, there was one individual study that demonstrated massage therapy significantly improved sleep duration even after 24 weeks of follow-up. More research is needed to determine if there are sleep effects from massage therapy for patients with fibromyalgia.
Of note, no adverse events were reported in any of the 10 studies of massage therapy for fibromyalgia.

Variability
Several limitations exist within this review. First, there was great variability among the subjects in these studies, with ages ranging from 19–90, and the duration of diagnosis ranging from 1–14 years. Such variability makes it difficult to determine the type of patient who might benefit the most from massage. Perhaps all patients with fibromyalgia would benefit from massage therapy, but we cannot determine that from the current findings. Second, there was great variability in the massage treatment provided. Massage time ranged from 25–90 minutes, total sessions ranged from 1–20, and study duration ranged from 1–24 weeks.
From these data, we cannot determine the most effective amount and duration of care for patients with fibromyalgia, other than to say that treatment is most beneficial if provided for at least five weeks. Finally, based on these results, we cannot determine the benefit of massage when combined with other therapies. Most patients with fibromyalgia visit several health-care providers and seek multiple treatments. Through these studies, we cannot determine what combination of care would be most beneficial for fibromyalgia patients.

Conclusion
The conclusions of this research review can be summarized as follows:
1. At least five weeks of massage therapy is likely needed to demonstrate pain reduction in fibromyalgia patients. Your clients may improve sooner than five weeks; however, you should let them know they might not see substantial results right away.  
2. Fibromyalgia patients may also experience improvement in anxiety and depression after five weeks of massage therapy. Again, let your clients know it might take time before they see substantial results.
3. There is little evidence that massage therapy helps fibromyalgia clients with their sleep patterns. More research is needed on this topic.
4. Massage therapy may not help all clients with fibromyalgia. Even though it appears most clients will benefit from massage, we do not yet know if there are certain types of clients who are less likely to respond. We also do not know the best massage treatment protocol for fibromyalgia patients. Use your best judgment in deciding treatment types, time, and duration.
5. Massage therapy is expected to be safe for patients with fibromyalgia, as evidenced by no adverse reactions in any of the studies reviewed. However, be sure to assess your clients for other comorbidities or contraindications for massage.

Notes
1. Mayo Clinic, “Fibromyalgia,” accessed January 2015, www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/definition/con-20019243.
2. National Institute of Arthritis and Musculoskeletal and Skin Diseases, “Questions and Answers about Fibromyalgia,” accessed January 2015,
www.niams.nih.gov/Health_Info/Fibromyalgia.
3. Yan-hui Li et al., “Massage Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” PLoS ONE 9, no. 2 (2014).

Jerrilyn Cambron, DC, PhD, MPH, LMT, is an educator at the National University of Health Sciences and president of the Massage Therapy Foundation. Contact her at jcambron@nuhs.edu.