Multiple sclerosis (MS) is a disease of the central nervous system. The most common symptoms are overwhelming fatigue, visual disturbances, altered sensation, and difficulties with mobility. Approximately 2.3 million people are affected by MS worldwide.1 Exact figures are difficult to calculate because MS symptoms can be nearly invisible and MS is not a disease with mandatory government reporting.
Treatment of MS is frequently sought through disease-modifying medications along with other medications for symptom relief. Massage therapy is one of the most commonly used complementary and alternative medicine treatments. However, very little is known about the benefits of massage therapy for MS.
In a 2014 study, Brittany Schroeder and a team of researchers evaluated the effects of massage therapy on quality of life and leg function in individuals with MS.2 Twenty-four Canadian subjects who had a moderate disability score (between 3.5 and 7.0 out of 10 on the Expanded Disability Status Scale) enrolled in the study. Potential subjects were excluded due to chest pain (unstable angina) or heart attack during the previous month, high blood pressure, or inability to attend regular massage appointments. Eighteen of the 24 subjects previously used massage, and therefore had some experience with this form of care.
Subjects were initially randomized to one of two groups. Group 1 received 45-minute whole-body Swedish massages twice a week for four weeks. Prior to the start of the study, the massage therapists practiced the standardized massage routine, and the routine was then posted at the head of the massage table during the study as a reminder for the therapists. The four weeks of massage sessions were followed by four weeks of twice weekly rest (no care) as a comparative control. Group 2 started with four weeks of rest two times a week, and then received twice weekly massage therapy during the second four weeks (weeks five through eight).
The crossover of patients from massage therapy to no care or from no care to massage therapy allowed data to be collected from all 24 subjects in the no care and the massage care situations. In other words, subjects served as their own control.
Several outcome measures were collected within this study. Immediately after each massage session, the subject completed a brief questionnaire to determine the degree of similarity between each treatment. The massage therapist also completed a brief questionnaire defining the duration of treatment and observed changes in the subjects. On a weekly basis, the subjects completed a three-question health assessment to log any stressors that may have aggravated their MS symptoms. Based on these measures, there were no reported differences in the massage technique or duration. There were also no changes in self-reported health status throughout the study between the two groups.
Subjects also completed three other outcome measures at the start of the study, the end of four weeks, and the end of eight weeks. First, a six-minute walk test (6MWT) was completed to determine exercise capacity as a measure of leg function. Second, the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) survey was used to measure different aspects of physical, mental, emotional, and social health. Finally, the Expanded Disability Status Scale (EDSS) was used to collect and measure the level of disability.

The Findings
No statistically significant changes were found in the 6MWT, HAQUAMS, or EDSS measures due to massage treatment when compared to rest. However, the subjects in group 1 who had worse disease severity had significantly better walking distances on the 6MWT and also better HAQUAMS scores after four weeks of massage, demonstrating that massage may be of more benefit to MS subjects with more severe symptoms. No other differences in treatment were noted.
The majority of the subjects’ written comments were favorable, with 18 of the 24 subjects including positive statements and only three including negative statements. Positive comments included that the benefit of massage lasted several hours to several weeks and that massage helped with sleep and increased energy levels the next day.
Overall, there were no significant differences between massage and rest, although there were many positive written comments about the effects of massage treatment. Perhaps the study limitation of a small number of subjects did not allow for statistical significance to be discovered. Larger sample sizes typically allow for a more robust data analysis and should be considered in future trials. Also, the subjects’ MS may not have been severe enough to demonstrate significant improvement over time when compared to no treatment. There were pre/post changes in the massage group in subjects with more advanced MS, so perhaps a higher degree of severity of MS is needed in order to see a significant change in subjects’ outcomes. Finally, there was no justification as to why the treatment schedule of two 45-minute massage treatments per week for four weeks was chosen. A different schedule of care might have had a greater effect.
In a related study led by P. A. Mackereth, 50 subjects with MS in the United Kingdom were randomized to either progressive muscle relaxation or reflexology for six sessions of treatment.3 After the six sessions, subjects crossed over to the other group for six sessions of the opposite form of care. Several types of outcome measures demonstrated positive effects for both treatments, with limited differences between the groups. However, some of the most interesting data came from the conversations during the care.
To collect data on the conversations during care, subjects in both groups were audiotaped and the conversations were transcribed to assess the verbal expressions of feelings.4 Of the 300 reflexology sessions, 245 audiotapes were available for assessment. Transcripts were explored for common themes and were reread for specific issues and perspectives. These items were clustered in areas of commonality. Two raters reviewed the transcripts for themes, and differing views were discussed and agreed upon.
The researchers found there were four common themes discussed by the subjects during the treatment sessions. The common themes surrounded their worries and concerns regarding: (1) physical health and treatment, such as symptoms of fatigue, pain, bladder and bowel problems, diagnosis experiences, treatment, and interactions with health professionals; (2) psychological concerns, such as worry, anxiety, depression, anger, frustration, future, body image, isolation, and loss issues; (3) home and family, such as relationships, financial issues, and domestic activities; and (4) work and leisure, such as sick leave, part-time, work stresses, retirement reaction from colleagues, and effects on social and leisure activities.
Study limitations may narrow the application of these results. For example, the comments made by these clients may be different from what other clients experience. Also, the themes found by the researchers may be different from what other researchers would find in the data.

Conclusions
In a small-scale study focused on subjects with MS, massage therapy did not affect quality of life, walking, or disability when compared to rest. However, improvements in walking after massage were noted by subjects who had more severe cases of MS. Some subjects with MS also found that massage improved their sleep and increased their energy levels.
More research is needed to better understand which symptoms might be improved by massage, particularly at different stages of the disorder.
People with MS may express concerns about life issues during a treatment session, highlighting the need for therapists to know when and how to refer to other health-care professionals or social-service agencies.
All clients are different—particularly clients with MS—due to the nature of the disorder. Talk to your clients with MS and their health-care teams to determine the best course of treatment.

Notes
1. National Multiple Sclerosis Society, “Multiple Sclerosis FAQs,” accessed November 2015, www.nationalmssociety.org.
2. B. Schroeder, J. Doig, and K. Premkumar, “The Effects of Massage Therapy on Multiple Sclerosis Patients’ Quality of Life and Leg Function,” Evidence-Based Complementary and Alternative Medicine (May 8, 2014).
3. P. A. Mackereth et al., “Reflexology and Progressive Muscle Relaxation Training for People with Multiple Sclerosis: A Crossover Trial,” Complementary Therapies in Clinical Practice 15, no. 1 (February 2009): 14–21.
4. P. A. Mackereth et al., “What Do People Talk About During Reflexology? Analysis of Worries and Concerns Expressed During Sessions for Patients with Multiple Sclerosis,” Complementary Therapies in Clinical Practice 15, no. 2 (May 2009): 85–90.

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.