Massage Therapy Journal Club ep 2: Moraska & Chandler (2008)

Join us today at 4:30 Mountain Standard Time for the latest episode of the Massage Therapy Journal Club.  I will be joined by Jennifer Barrett, Lauren Davis, Til Luchau, Alice Sanvito, and Ravensara Travillian to discuss a study published by Moraska & Chandler entitled “Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study.”

You can use this link to watch live or the recording after the episode has aired.

Here is an outline of the article that we may use to facilitate the discussion:


Moraska, A., & Chandler, C. (2008). Changes in clinical parameters in patients with tension-type headache following massage therapy: a pilot study. The Journal of Manual & Manipulative Therapy, 16, 106-112.


Focus is on tension-type headache (TTH)

Most prevalent type

Lack of effective medical options may drive popularity of non-pharmaceutical options

Forty percent of patients visiting a headache clinic reported using one or more CAM modalities

Some (est. 25%) TTH sufferers engage in self-massage for pain relief

Previous studies

Puustjarvi et al. (1990) found that massage reduced TTH frequency in women, including at 6mo follow-up

Quinn et al. (2002) conducted a case series using highly trained massage therapists and found as little as two 30min massage sessions reduced headache frequency 50%

Nature of TTH

Muscular involvement

Physiological and physical abnormalities

Increased tenderness

Greater incidence of myofascial trigger points

Forward head posture

Reduced cervical muscle strength and endurance

Study objective was to “evaluate a specific massage therapy treatment dirercted at cervical and cranial musculature on primary and secondary measurers of headache as well as a measurer of disability associated with headache” (p. 107)


Study design

3-wk baseline period

6-wk treatment period

Biweekly 45min massage treatments

Massage directed to soft tissues of cervical and cranial regions

3-wk follow-up period

Daily headache diary

Headache Disability Index administered at 3-wk intervals


Conformed to international Headache Society guidelines for episodic or chronic TTH

Regular headache pain prior 6+ mos

Headaches lasting 4+ hrs

21-65 yrs of age

<1 migraine headache per month

Subject recruitment via newspaper and flyers at local physician offices

18 subjects enrolled, 2 dropouts/removals = 16 subjects for data analysis

Twelve of sixteen were women

Mean age = 43.8 yrs, range was 28 to 56

In prior six months four reported having received no massage, twelve reported having received at least one massage from a professional massage therapist

Massage therapists

Six therapists

Mean = six years professional experience

All received 6 hrs specific training in treatment protocol for this study

Subjects received all treatment from same therapist for duration of study

“To isolate the effect of the massage procedure from therapist-subject camaraderie, therapists and subjects were directed to minimize conversation…” (p. 107)

Therapists were not informed about subject progress during the study

Massage protocol

Two 45m sessions per week across six-week treatment period

Each session separated by at least 48 hrs


First 15min = palmar strokes to “warm-up” tissues of back, shoulders, chest, and neck

Middle 15min = up to six myofascial trigger points palpated and treated; muscles addressed included upper trapezius, sternocleidomastoid, suboccipital, and splenius capitis

Final 15min

5min post-isometric relaxation directed to lateral cervical flexion

5min circular or cross fiber friction on masseter, temporalis, and occipital-frontalis muscles

5min gentle effleurage and petrissage on neck and shoulders


Headache diary

Completed daily before bedtime

Indicate if TTH occurred


Peak intensity on 0-100 scale

Headache disability index

25-item standardized measure of TTH impact on daily living

Separate emotional and functional subscales

Was administered 5x at 3wk intervals

Was never administered on same day as massage was administered

Data analysis

Headache measures averaged for each 3wk phase

Repeated measures ANOVA (i.e., this is a within-group study with no separate control group)


Headache frequency

Decreased significantly across time


Baseline period = 4.7

Tx period 1 = ? (estimated 4.6 from graphic)

Tx period 2 = 3.7

Follow-up period = 3.2

Headache intensity

Decreased significantly across time


Baseline period = 46.9

Tx period 1 = ? (estimated 38 from graphic)

Tx period 2 = ? (estimated 33 from graphic)

Follow-up period = 32.8

Headache duration

Decreased significantly across time (but not as uniformly as other effects)


Baseline period = 4.0

Tx period 1 = ? (estimated 4.2 from graphic)

Tx period 2 = 3.4

Follow-up period = 2.8

Headache Disability Index

Total and subscale scores decreased across time

Means for total score

Baseline period = 44.2

Tx period 1 = ? (estimated 37 from graphic)

Tx period 2 = ? (estimated 24 from graphic)

Follow-up period = 25.1

Similar trajectories for Functional and Emotional subscales


Summary of results is restated

Observation that improvements generally persisted or continued in follow-up phase

Detailed discussion of trigger point theory

Consideration of whether longer (60min) treatments might be superior

Consideration of whether early phase of treatment is a period of becoming accustomed to treatment

Noted that observed 19.1 point improvement on Headache Disability Index does not meet 29 point improvement that some have said is indicative of “clinical significance”

“The comparison to a baseline standard and not a placebo control group limits the ability to assess causality of the treatment” (p.111)


“The observed improvement in clinical headache parameters provides an intriguing look into the therapeutic effect of massage and is encouraging for placebo-controlled research in complementary and alternative treatments for TTH” (p. 111)


Discussion points and questions

What specific challenges might arise when studying treatment of headache?

Symptoms were generally reduced to a statistically significant degree – what the possible explanations for this finding?  How is the study limited by not having a control group?

The Discussion section of the paper includes much discussion of trigger point theory.  How important is that theory in relation to this study?  Is this study a test of trigger point theory?