Complementary Therapies in Medicine 71 (2022) 102892

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

The effect of massage therapy on pain after surgery: A comprehensive

meta-analysis
Chunhua Liu a, Xiang Chen b, Simin Wu a, *
a
Department of Cancer Rehabilitation, Lishui Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang University of Traditional Chinese Medicine, Lishui,
Zhejiang, China
b
The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China

A R T I C L E I N F O A B S T R A C T

Key Words: Background: Findings on the usefulness of massage therapy (MT) in postoperative pain management are often
Postoperative pain inconsistent among studies.
Massage therapy Objectives: This study’s aim is to conduct a meta-analysis of randomized controlled trials (RCT) to clarify the
Meta-analysis
effects of massage therapy in the treatment of postoperative pain.
Randomized controlled trials
Methods: Three databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) were searched
for RCTs published from database inception through January 26, 2021. The primary outcome was pain relief.
The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. The random-effect model
was used to calculate the effect sizes and standardized mean difference (SMD) with 95 % confidential intervals
(CIs) as a summary effect. The heterogeneity test was conducted through I2. Subgroup and sensitivity analyses
were used to explore the source of heterogeneity. Possible publication bias was assessed using visual inspection
of funnel plot asymmetry.
Results: The analysis included 33 RCTs and showed that MT is effective in reducing postoperative pain (SMD,
− 1.32; 95 % CI, − 2.01 to − 0.63; p = 0.0002; I2 = 98.67 %). A similar significant effect was found for both short
(immediate assessment) and long terms (assessment performed 4–6 weeks after the MT). Remarkably, we found
neither the duration per session nor the dose had an impact on the effect of MT and there seemed to be no
difference in the effects of different MT types. In addition, MT seemed to be more effective for adults.
Furthermore, MT had better analgesic effects on cesarean section and heart surgery than orthopedic surgery.
Limitations: Publication bias is possible due to the inclusion of studies in English only. Additionally, the included
studies were extremely heterogeneous. Double-blind research on MT is difficult to implement, and none of the
included studies is double-blind. There was some heterogeneity and publication bias in the included studies. In
addition, there is no uniform evaluation standard for the operation level of massage practitioners, which may
lead to research implementation bias.
Conclusions: MT is effective in reducing postoperative pain in both short and long terms.

1. Introduction year1–6. Indeed, postoperative pain is often poorly controlled with

Postoperative pain is a longstanding issue during post-surgery re­
covery and has become the main healthcare goal in many medical dis­
ciplines1. With aging and a growing population, more than 280 million
procedures including joint replacement, cardiovascular and cerebro­
vascular surgeries, and cancer surgeries are performed globally every
inadequate treatment7–9. Importantly, ineffective postoperative pain
control is associated with poor prognosis, including longer hospital
stays, sleep disturbances, longer time to resume activity, and increased
use of opioids10–13. Traditional analgesic measures with drugs (e.g.,
opioid) only for pain relief are not only far from achieving the desired
effect, but also cause multiple somatic and psychological sequelae

Abbreviations: MT:, massage therapy; RCT:, randomized controlled trial; SMD:, standardized mean difference; CAM:, complementary and alternative medicine;
SCCM:, Society of Critical Care Medicine; MD:, mean difference; CI:, confidential interval.
* Correspond to: Department of Cancer Rehabilitation, Lishui Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang University of Traditional Chinese
Medicine, 800 Zhongshan Street, Lishui City, Zhejiang province, 323000, China.
E-mail addresses: 850189196@qq.com (C. Liu), 516307535@qq.com (X. Chen), 1822698677@qq.com (S. Wu).

https://doi.org/10.1016/j.ctim.2022.102892
Received 10 February 2022; Received in revised form 30 August 2022; Accepted 17 October 2022
Available online 26 October 2022
0965-2299/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
C. Liu et al.
Fig. 1. Workflow of the systematic review.
including depressive disorders, anxiety, disorders, sleep disorders, sex­
ual dysfunction, and delirium14,15.
On the other hand, pharmacological control measures as well as
complementary and alternative medicine (CAM) can improve the effi­
cacy of postoperative pain control. In fact, CAM has been advocated for
pain control by multiple governments and professional organizations
such as the American Society of Clinical Oncology, the National
Comprehensive Cancer Network, and the Society of Critical Care Med­
icine (SCCM)16–18. Complementary therapies such as massage,
acupuncture, body and mind therapy, and relaxation therapy can be
used together with traditional therapies to reduce postoperative
pain19–29. As one of the most popular non-drug therapies, massage
therapy (MT) is defined as the therapeutic manipulation by the use of
hands or mechanical devices for maintaining the suppleness of the
body30. Importantly, it was reported that MT reduces pain and anxiety
2
Complementary Therapies in Medicine 71 (2022) 102892
for some patients after surgery10.
Despite a growing number of studies in the field, a comprehensive
understanding of the impact of MT for postoperative pain control in
multiple surgical procedures is still lacking31–34. To date, it is unclear
how the massage dose and duration would impact postoperative pain
relief10,35. The long-term benefits of MT have not been analyzed.
Furthermore, previous meta-analyses most were limited to cardiac sur­
gery, and no other types of surgery were analysed36–41.
To critically evaluate current available randomized controlled trials
(RCTs), we conducted a systematic review and meta-analysis for a better
understanding of postoperative pain control by MT. Specifically, we
focused on the following key questions:1 Is MT effective in reducing
postoperative pain in both immediate and delayed assessments?2 Is
there a dosage effect?3 Does the duration per MT session have an impact
on the effectiveness?4 Is the effect of MT universal for different types of
 Table 1

C. Liu et al.
Characteristics of Included Studies.
Study Country Types of Design Massage Post of Control Outcome Measurement
surgeries (arm) Group days Group timepoint

Sample Age Female Practitioner Massage Type Body Part Duration 0 Sample Age (year) Female Intervention
size (year） (%) Per session 1 size (%)
(minutes)/ 2
Total …
session
Albert, N. M., et al.2009 USA CS1 RCT, 2 126 65 ± 12 0.29 MT Standardized Extremities 30/2 5 126 65 ± 12 0.25 Usual Care VAS POD4/5
Bauer, B. A., et al.2010 USA CS1 RCT, 2 62 65 ± 12 0.68 MT Integrative PT’s choice 20/2 4 51 66 ± 14 0.71 Standard care VAS POD2/3/4
therapy (unclear
specific therapy)
Boitor, M., et al.2015 Canada CS1 RCT, 2 21 67.9 0.19 RN Standardized Hands 15/2–3 1 19 66.5 0.26 Hand holding FPT POD1
± 10.2 ± 11.0
Boitor, M., et al. 2018 Canada CS1 RCT, 3 20 36–78 0.3 TN Standardized Hands 20/2 1 21 44–84 0.238 Standard care NRS 0/0.5 h
Braun, L. A., et al.2012 Australia CS1 RCT, 2 75 66.8 0.23 MT Swedish PT’s choice 20/1 6 71 66.6 0.18 Rest time VAS 10 min,
± 11.3 ± 11.7 POD4/5
POD5/6
Bulut, M., et al.2020 Turkey Ci RCT,4 35 7.20 unclear TR Standardized Hands 20/1 1 35 7.20 unclear Unclear WB- 0.5/2 h
± 0.79 ± 0.67 FACES
Büyükyılmaz,F.and T. Turkey THA, RCT, 2 33 57.2 0.733 TR Standardized Back 10/1 3 30 59.2 ± 14 0.667 Relaxation VAS, 0/1/2 h
Aştı.2013 TKA ± 13.9 MPQ
Cankaya, A. and S. Turkey LC RCT, 2 44 48.45 0.773 R Standardized Feet 10/1 6 44 51.38 0.705 Routine care NRS 0
Saritas.2018 ± 14.8 ± 13.88
Chandrababu, R., India CABGS RCT, 2 65 57.62 0.154 MT Standardized Feet 20/4 5 65 57.46 0.185 Usual care VAS POD5
et al.2020 ± 7.49 ± 8.49
Cho, Y., et al.2016 Korea BCS RCT, 2 21 46.6 ± 6.8 unclear PT Manual Arms 30/20 28 20 50.7 ± 9.6 unclear Physical NRS POD28
lymphatic therapy
drainage
3

Cutshall, S. M., USA CS1 RCT, 2 30 64.3 0.68 MT Swedish PT’s choice 20/4 5 28 68.1 0.71 Usual care VAS POD5
et al.2010 ± 16.85 ± 14.57
de Jong, M., et al. 2012 Netherlands CFS RCT, 3 20 11.5 ± 8.9 0.15 TN ‘M technique
′
PT’s choice 10/1 1 19 10.8 ± 5.5 0.35 Standard care NRS 1h
massage
Demir, B. and S. Turkey LT RCT, 2 40 46.87 0.175 TN Standardized Hands 10/1 1 40 44.85 0.275 Face-to-face VAS 0
Saritas.2020 ± 13.83 ± 11.67 interview
Ebert, J. R., et al.2013 Australia TKA RCT, 2 24 70.848–89 0.292 MT Manual Operated 30/3 42 26 69.251–87 0.269 Physical NRS POD42
lymphatic limb therapy
drainage
Eghbali, M., et al.2010 Iranian AKS RCT, 2 30 29.47 0 R Standardized Foot, hands, 20/1 1 30 29.33 0 Routine care VAS 0
± 7.17 shoulders ± 7.39
Gol, M. K. and D. Iran Ma RCT, 3 30 44.12 1 Pt, TC Manual Arms and 20/30 30 30 45.81 1 Usual care VAS POD30
Aghamohamadi.2020 ± 6.09 lymphatic armpits ± 7.01

Complementary Therapies in Medicine 71 (2022) 102892

drainage
Harrison, T. M., USA CS1 RCT, 2 30 12month≤ unclear MT Swedish Limb、 30/7 7 30 12month≤ unclear Routine care FLACC POD7
et al.2020 head、 face
and back
Hattan, J., et al.2002 England CS1 RCT, 3 9 unclear unclear MT Standardized Feet 20/1 unclear 7 unclear unclear Usual care VAS 0
Irani, M., et al.2015 Iran CS2 RCT, 2 40 29.25 1 R Standardized Extremities 20/1 1 40 29.35 1 Chat with VAS 0/1/1.5 h
± 4.78 ± 4.88 them
Kim, S. M., et al.2015 Korea TKA RCT, 2 8 70.8 ± 5.4 0.625 ME Mechanical PT’s choice 20/5 7 10 75.6 ± 5.1 0.8 Usual care NRS POD7
massage
Koraş, K. and N. Turkey LC RCT, 2 85 ≥ 18 year 0.718 R Standardized Feet 20/1 1 82 ≥ 18 year 0.683 Standard care VAS 5 min,
Karabulut.2019 0.5/1/1.5/2 h
Miller, J., et al.2015 England Surgery RCT, 2 25 61.2 0.48 MT Standardized Hand and 5/1 1 25 61.2 0.48 Standard care NRS 5/45 min
± 11.5 arms ± 11.5
Mitchinson, A. R., USA TS, AS RCT, 3 200 63.5 0.98 MT Standardized Back 20/5 5 203 63.8 0.985 Standard care VAS POD1/2/3/4/
et al.2007 ± 10.3 ± 10.1 5
Mizrak Sahin, B., et al. Sweden AH, SO RCT, 3 15 51.86 1 R Unclear Hand 20/1 1 15 51.33 1 Standard care VRS 0.5/3 h
2020 ± 8.7 ± 7.32
(continued on next page)
 C. Liu et al. Complementary Therapies in Medicine 71 (2022) 102892

surgeries?5 Are there differences in the effect of different types of MT?6

TC= trained companion; RN= research nurse; ME= massage equipment. CS1 = Cardiac Surgery; TKA = Total Knee Arthroplasty; THA = Total Hip Arthroplasty; Ci = Circumcision; LC = Laparoscopic Cholecystectomy;
Abbreviations: FPT = Faces Pain Thermometer; MPQ= McGill Pain Questionnaire short-form; VAS =visual analog scale; VRS=Verbal Rating Scale; NRS= Numeric Rating Scale; FLACC= Face, Legs, Activity, Cry,
Consolability behavioral pain assessment tool; WB-FACES= Wong-Baker FACES pain rating scale. Pt= patient; MT= massage therapist; PT= physical therapist; R= researcher; TR= trained researcher; TN= trained nurse;

SO = Salpingo oophorectomy; TSFS = Tibial Shaft Fracture Surgery; SS = Sternotomy Surgery; AS = Abdominal Surgery; AKS = Arthroscopic Knee Surgery,Ma = Mastectomy, Integrative therapy (unclear specific
CABGS = Coronary Artery Bypass Graft Surgery; BCS = Breast Cancer Surgery; CFS = Craniofacial Surgery; LT = Liver Transplantation; CS2 = Cesarean Section; TS = Thoracic Surgery; AH = Abdominal Hysterectomy;
Is there a difference in the effect of MT on children and adults?

POD1/2/3/4/
Measurement

0/0.5/1/2 h

0.5/1/1.5 h
POD1/2/3
timepoint

POD4/6
0.5/2 h

0/1.5 h
2. Methods

5/6/7
1h

1h
This systematic review was performed in accordance with the
Outcome

PRISMA (Preferred Reporting Items for Systematic Review and Meta-

NRS

Standard care NRS

NRS
VAS

VAS

VAS

Standard care VAS

Standard care VAS

Standard care VAS

Analysis) guidelines42. The International Prospective Register of Sys­
tematic Reviews (PROSPERO) registration number was
Standard care
Standard care
Just stay with

Just stay with

CRD42021256822.

Usual care
them

them

2.1. Search strategy

unclear

Three databases (PubMed, Embase, and Cochrane Central Register of

0.457

0.691

0.758
0.18
0.2

Controlled Trials) were searched for RCTs published from the database
1

inception through January 26, 2021. The search strategy consisted of 3

≥ 18 year

components: clinical condition (pain*/postoperative pain, analgesi*),

± 4.451
unclear
± 7.52

± 3.22

± 7.34
20–50

21–25
60.25

27.75

31.96

72.82

intervention (massage, massag*, therapeutic therapy, therapeutic touch,

61.9

reflexology therapy, acupressure therapy, myotherapy, rolfing therapy,

Control

reiki therapy, polarity and therapy, jin and shin therapy, neuromuscular
Group

therapy, pfrimmer and therapy, alexander technique, feldenkrais and

35

35

33
55

52

30

55

68

33

method, myofascial release, shiatsu or tui na, trigger point, therapeutic

Post of

touch, therapeutic therapy, trigger point), and study type (randomized

days

clinical trial). The star symbol (*) was used for truncation search. The
1

1
7

search used a combination of subject terms and free words, and traces
the references of the included documents to supplement the acquisition
30/1

10/1

10/1
10/7

10/1

20/3

20/1

20/1

30/2

of relevant documents. Details of the strategy are provided in Appen­

dix1. A manual search was also performed on the reference listed in the
Feet and legs

Operated leg

published literature to ensure completeness. For studies that were only

PT’s choice

Hands and
Patient’s

presented at a conference, the authors were contacted for acquisition of

Unclear
choice

the data.
Back

Feet

Feet
feet

2.2. Eligibility criteria and study selection

Thailand classic

Tissue Massage
Standardized

Standardized

Standardized

Standardized

Standardized
Connective
Effleurage

lymphatic

In general, the Participants, Interventions, Comparators, Outcomes

drainage
Manual

and Study design (PICOS) framework was followed43. RCTs that met the
therapy) = Combination of several massage techniques, but it is not clear which techniques are used.

following criteria were included: (i) Patients (P) undergone surgery; no

restrictions based on participant, sex, race, or the type of surgery. (ii)
Included interventions (I): treatment with MT (manual or instrument),
manual lymphatic drainage or combination treatments for patients after
MT

MT

MT

MT
TR
TC

R
R

surgery. MT is defined as the manipulation of soft tissues that requires

physical contact. Thus, studies on reiki therapy, therapeutic touch, and
unclear
0.457

0.279

0.788
0.21

0.73

therapeutic touch that do not require physical contact were excluded.

1

Reflexology and Shiatsu therapy were excluded because the purpose was
to stimulate the trigger point. The intervention group can be one or
≥ 18year
± 5.049
unclear
± 7.11

± 2.77

± 7.09
20–50

21–25

more. (iii) The control group (C) was composed of individuals who
59.28

27.04

32.25

71.30
60.1

received routine care, rest, relaxation, physical therapy, face to face

chat, and fake MT. Studies that used massage as a control group (e.g.,
Types of Design Massage
surgeries (arm) Group

MT with or without essential oil; aromatherapy hand massage vs. body

RCT, 2 35

RCT, 2 43

RCT, 2 33
RCT, 3 81

RCT, 3 52

RCT, 2 30

RCT, 3 55

RCT, 3 63

RCT, 3 33

massage; massage vs. massage plus acupuncture) were excluded. (iv)

Outcomes (O) included pain assessment regardless of the scale used. (v)
Only RCTs written in English were included.
The eligibility of retrieved studies was manually checked by reading
CABGS

the title, abstract, or full text as needed by two researchers (CH Liu and
SS, AS
TSFS

TKA
1

CS2

SM Wu) independently. The opinion of a third reviewer (X Chen) was

LC
CS

CS

CS

used to resolve any disagreement.

Country

Turkey

2.3. Data collection and assessment of quality of study

Italy
Okvat, H. A., et al.2002 USA

USA

USA

USA
Najafi, S. S., et al.2014 Iran

Iran

Iran

Tornatore, L., et al.2020

Using predesigned forms, studies were examined independently for

Saatsaz, S., et al.2016
Pasyar, N., et al.2018
Table 1 (continued )

the following information: participants, study description, study loca­

Sözen, K. K. and N.
Piotrowski, M. M.,

Sharma, K. and R.

Karabulut.2020
Simonelli, M. C.,

tion, number of patients in each group, type of surgery, duration, fre­

Kumari.2019

quency, body part, provider of the MT, pain assessment method, pain
et al.2003

et al.2018

intensity (pre- and post-intervention), and assessment of overall

Study

research quality. The quality of a study was evaluated using the

Cochrane Collaboration’s risk of bias assessment tool44. Each RCT was

4
C. Liu et al. Complementary Therapies in Medicine 71 (2022) 102892

assigned a low, high, or unclear bias based on six specific areas

(sequence generation, allocation hiding, participant blindness and
outcome evaluation, incomplete outcome data, selective outcome re­
ports, and other potential threats).

2.4. Statistical Analysis

Meta-analysis was performed by calculating the effect size and 95%

CI using the random effect model. Heterogeneity among trials was
identified by the χ2 test and reported as I2. For studies with comparable
measurement scales, mean difference (MD) was used to assess the
magnitude of the treatment effect45. Otherwise, standardized mean
difference (SMD) was used46. Two-sided p < 0.05 was considered sta­
tistically significant.
Subgroup analysis was conducted to explore potential sources of
heterogeneity, which included MT effect (immediate assessment versus
delayed assessment), MT dosage (single versus multiple), duration of MT
per session (20 min as a cutoff), type of surgery (cardiac surgery, ce­
sarean surgery, orthopedic surgery), type of MT (standard versus
Swedish), and study population (adults versus children).
Publication bias was assessed by funnel plots and the Egger test for
asymmetry when at least 10 trials were included47. All statistical ana­
lyses were performed with Stata (version 16.0, Stata Corp LLC).

3. Results

3.1. Study selection

The workflow of the systematic review is shown in Fig. 1. A total of

12,470 articles were identified through database search. After removing
duplicates (n = 5341) and examining the article details (title and ab­
stract, n = 6887), 242 studies remained. Further evaluations led to the
exclusion of 209 studies for unavailability of data (n = 20), improper
intervention (such as Reiki, Shiatsu, n = 88), being non-RCTs (n = 14),
improper research design (such as random sampling only, n = 3), being
non-English articles (n = 21), being meeting abstracts only (n = 2), and
being clinical registration trials without data (n = 61). Thus, 33 stud­
ies19–25,29,48–72 were included.

3.2. Study Characteristics

The study characteristics of 33 RCTs are summarized in Table 1. In

total, they involved 3243 patients with postoperative pain and were
conducted in multiple countries. For the type of the surgery, the main
one is cardiac surgery19,20,23,24,48–50,56,57,64,65, others such as circumci­
sion surgery21, total hip or knee arthroplasty29,54,59,72, laparoscopic
cholecystectomy22,60,71, cesarean section58,68–70, etc. A variety of MT
treatments were used in the selected studies with classic (Swedish) and
standard MT as the dominant ones. In addition, most providers of MT
were massage therapists or physical therapists (n = 15); other MT pro­
viders included trained nurses and researchers (n = 16), patients’
partners (n = 2)25,64, and massage equipment (n = 1)59. While partici­
pants in most studies were adults (n = 30), children participated in three
studies21,52,56. The body parts for massage included the back, hand, feet,
whole body, or body parts selected by the participant. The duration per
session ranged from 5 to 30 min, and the dosage was one, two, or more
times.
Different measures were used in these studies to assess the results,
the most used are Visual Analog Scale (VAS) and Numeric Rating Scale
(NRS), others include Faces Pain Scale (FPS), Verbal Rating Scale (VRS),
etc. None of the selected studies reported adverse effects.

Fig. 2. Risk of bias summary. “+ ” means low risk bias; “?” means unclear risk 3.3. Risk of bias within studies
bias; “-” means high risk bias.

Two researchers independently analyzed the risk of bias in these

RCTs (Figs. 2 and 3). Twelve of the 33 studies did not report the

5
C. Liu et al.
Fig. 3. Deviation chart for risk of bias.
randomization method, and 20 did not indicate the problem of alloca­
tion concealment. While no study implemented blinding of participants
due to the type of intervention, 27 studies implemented blinding for the
evaluation of results. We also noted that pain assessment by the patient
would lead to inevitable bias because it is subjective.
2. Synthesis of results
Meta-analysis of data from all 33 studies using a random-effects
model showed that the effect of MT for patients with postoperative
pain was significant (Fig. 4, Table 2) with considerable heterogeneity
(SMD, − 1.32; 95 % CI, − 2.01 to − 0.63; p = 0.0002; I2 = 98.67 %). We
then evaluated the effect of MT for both short (immediate assessment,
n = 19) and long terms (assessment performed 4–6 weeks after the MT,
n = 3) separately. Remarkably, we found similar significant effects
(p = 0.001 and p = 0.001 for short and long terms, respectively).
However, a much lower heterogeneity was found in the long-term
studies (I2 = 98.82 % and I2 = 0.00 % for short and long terms,
respectively). For delayed assessment, 11 studies performed measure­
ments one week after MT and showed a significant effect of MT in
reducing postoperative pain with considerable heterogeneity (SMD,
− 0.56; 95 % CI, − 1.04 to − 0.08; p = 0.02; I2 = 94.11 %).
Subgroup analyses on the dose (Table 2) showed a significant post­
operative pain relief by single-dose MT with considerable heterogeneity
(SMD, − 1.73; 95 % CI, − 2.79 to − 0.68; p = 0.001; I2 = 98.88 %) from
20 studies. In addition, results from multiple-dose studies (n = 13) also
showed statistical significance with considerable heterogeneity (SMD,
− 0.65; 95% CI, − 1.04 to − 0.26; p = 0.001; I2 = 91.05 %). Of note, two
of the 20 single-dose studies involved both single dose and multiple
doses20,49. While data from single-dose studies were extracted, those
from multiple-dose experiments can not be accessed because they were
only presented in graphs without raw numbers.
To assess the effect of MT duration (Table 2), we selected studies in
which the evaluation was performed at the same time after a single-dose
MT. In six studies with 5–20 min of MT per session, we found a signif­
icant effect with considerable heterogeneity (SMD, − 3.23; 95 % CI,
− 6.41 to − 0.05; p = 0.047; I2 = 99.45 %). Similarly, in another 6 studies
with MT sessions longer than 20 min, we also found a significant effect
with heterogeneity (SMD, − 0.74; 95 % CI, − 1.21 to − 0.27; p = 0.001; I2
= 78.30 %).
In addition, we also found variations among different types of sur­
geries (Table 2). While a statistically significant pain-reducing effect of
MT was found for patients after cardiac surgeries (11 studies, SMD,
− 0.61; 95 % CI, − 0.93 to − 0.29; p = 0.001; I2 = 81.45 %) and cesarean
surgeries (4 studies, SMD, − 4.00; 95 % CI, − 7.14 to − 0.86; p = 0.01; I2
= 99.02 %), no effect was found following orthopedic surgeries (7
studies, SMD, − 1.66; 95 % CI, − 3.79–0.46; p = 0.13; I2 = 99.06 %).
Finally, among different MT types (Table 2), pooled results from 19
studies using standard MT showed a statistical significance with
6
Complementary Therapies in Medicine 71 (2022) 102892
considerable heterogeneity (SMD, − 1.55; 95 % CI, − 2.45 to − 0.66;
p = 0.001; I2 = 98.76 %). By contrast, results from 3 studies with
Swedish MT revealed a significant effect with reduced heterogeneity
(SMD, − 0.56; 95 % CI, − 0.98 to − 0.14; p = 0.01; I2 = 61.87 %).
For study populations (Table 2), while 30 studies with adults showed
a statistically significant effect with considerable heterogeneity (SMD,
− 1.45; 95 % CI, − 2.2 to − 0.69; p = 0.001; I2 = 98.8 %), 3 studies with
children showed no statistical significance with moderate heterogeneity
(SMD, − 0.27; 95 % CI, − 0.63 to 0.09; p = 0.15; I2 = 31.52 %).
3. Publication bias
We aimed to conduct a comprehensive search to minimize publica­
tion bias by using three databases. Availability bias may exist due to the
inaccessibility of some RCTs from the authors46.
6. Discussion
Postoperative analgesic management is essential to ensure patient
comfort and a good course of treatment. The use of traditional drugs
such as opioids may produce outcomes that are far from ideal and can
bring about many side effects. On the other hand, MT is an important
alternative for pain control. We performed the first systematic review
and meta-analysis to evaluate the effects of MT following multiple sur­
gery types. With 33 RCTs and a total of 3243 patients, we found that MT
reduced postoperative pain in both short and long terms. In addition, no
correlation between the effect of MT and the dose and duration was
found. Interestingly, the efficacy of Swedish MT seemed to be not
different from that of standard MT. Subgroup analysis also revealed that
MT seemed to be more effective for adults and that MT had better
analgesic effects on cesarean section and heart surgery than on ortho­
pedic surgery. Thus, this research provides the latest comprehensive
evidence for relief of postoperative pain by MT and identifies research
gaps that remain to be resolved.
We found an impact of MT in both immediate and delayed assess­
ments, contrasting to a previous study in which the evaluation was
postponed35. Adams et al. in 2010 examined the impact of MT on pain
management for acute care and found that most patients benefited from
MT 1–4 h after surgery73. Lee et al. in 2015 showed that MT significantly
relieved cancer pain, especially in the short term, by performing a
meta-analysis74. MT may provide long-term pain relief by enhancing
circulation and rupture of adhesions and improving sleep75. More
well-designed long-term studies are needed to fully understand the
long-term effectiveness of MT in postoperative control.
A previous meta-analysis of MT showed that a single-dose inter­
vention was not statistically effective in the immediate assessment of
pain35. By contrast, we found that the effect of MT was not related to the
dose and type, which is consistent with the Gate Control Theory of Pain
Reduction76,77. For the duration of MT per session, we found that the
C. Liu et al. Complementary Therapies in Medicine 71 (2022) 102892

Fig. 4. The effect of massage therapy on overall postoperative pain.

7
C. Liu et al. Complementary Therapies in Medicine 71 (2022) 102892

Table 2
Meta-analysis of the effects of massage treatment in subgroup and sensitivity analysis.
Factor No. of Studies Participants Summary of SMD 95% CI of SMD P Heterogeneity (I2) Model Used

Assessment Time
Within three hours 19 1540 -1.78 -2.88 to − 0.69 0.001 98.82 % Random
With one week 11 1347 -0.56 -1.04 to − 0.08 0.02 94.11 % Random
Four to six weeks 3 182 -0.93 -1.24 to − 0.62 0.001 0.00 % Random
Dose of MT
Single dose 20 1686 -1.73 -2.79 to − 0.68 0.001 98.88 % Random
Multiple dose 13 1383 -0.65 -1.04 to − 0.26 0.001 91.05 % Random
Type of MT
Standard MT 19 2027 -1.55 -2.45 to − 0.66 0.001 98.76 % Random
Swedish MT 3 264 -0.56 -0.98 to − 0.14 0.01 61.87 % Random
The min of MT per session
< 20 min 6 474 -3.23 -6.41 to − 0.05 0.047 99.45 % Random
≥ 20 min 6 421 -0.74 -1.21 to − 0.27 0.001 78.30 % Random
Experimental subject
Adults 30 2781 -1.45 -2.2 to − 0.69 0.001 98.80 % Random
Children 3 189 -0.27 -0.63–0.09 0.15 31.52 % Random
Type of surgery
Cardiac surgery 11 979 -0.61 -0.93 to − 0.29 0.001 81.45 % Random
Cesarean surgery 4 379 -4.00 -7.14 to − 0.86 0.01 99.02 % Random
Orthopedic surgery 7 463 -1.66 -3.79 to 0.46 0.13 99.06 % Random

Abbreviations: SMD, standard mean difference; CI, confidence interval; Random, random-effect models; MT, massage therapy; VAS, Visual Analog Scale; NRS, Numeric
Rating Scale.

duration was not critical as a short session of MT treatment was still
effective. To the best of our knowledge, there is no direct assessment of
the effect of duration yet. Thus, further investigation is needed to justify
the minimal duration for effective MT treatment.
Unlike previous studies that only focused on certain types of sur­
geries, we included many surgery types and found that MT was effective
for cardiac surgery and cesarean section as reported in previous
studies10,33,40,78. However, it was not beneficial for orthopedic surgery,
possibly due to a late pain assessment schedule in these studies (4 days
after surgery). These results are in line with the fact that the pain
duration is dependent on the surgery type and that the degree of pain
drops rapidly in the first few days after the operation, especially on the
fourth day67,79.
Our analysis of different patient subgroups indicated that MT was not
effective for infants and young children. This is in line with a previous
analysis that assessed 11 studies using complementary and alternative
medicine (3 for MT) to treat childhood cancer pain80. It has been sug­
gested that young patients are not used to MT because they are afraid of
being touched by strangers52. Accordingly, the effect of MT has been
demonstrated when the MT provider is someone close to the child such
as the mother81. In addition, the effectiveness of MT in alleviating
postoperative pain in infants and young children should be reassessed
with more studies because only a small number of studies were included
here.
Due to the particularity of MT, blinding is almost impossible, which
increases the risk of bias. However, unblinded practical trials have been
recommended as they are applicable in the real world82. This design is
particularly suitable for studying complex and flexible interventions,
such as massage and acupuncture. Thus, they can be used to increase the
external validity for further studies.
Although available evidence suggests that MT is an important
component of postoperative pain management. However, the results
showed considerable heterogeneity. The biggest source of heterogeneity
may be related to MT method, i.e. the variations in type, site, pressure,
frequency, duration, practitioners, optimal intervention time, and
measurement time among MT regimens. For MT type, although some
authors concluded that it has no influence on MT effect75, others
recognized that there are about 100 different forms of MT in clinical
practice83 that need to be subjected to fair comparison among studies to
test the consistency of their efficacy84. In addition, it is also necessary to
study the contribution of each factor to the overall MT effect.
4. Limitations
There are several methodological limitations in this meta-analysis.
As a common limitation for all meta-analyses, the conclusions of this
study will be unreliable if the data from individual trials are flawed due
to biases in patient selection and detection of treatment effect. First, a
double-blinding design is difficult to implement for a trial of MT and
none of the selected studies met the double-blinding criterion. Although
some studies aimed to control the bias by holding the MT part or
applying light touch49, they still did not meet the double-blind standard
as they produced physiological effects83. The lack of blindness would
lead to detection bias and disrupt the final evaluation.
Second, selection bias is defined as the difference in baseline char­
acteristics among participant groups85. For example, some studies only
included female or male participants25,55,58,63,68–70. An early study
showed that men were more likely to benefit from MT than women86. In
addition, most studies focused on adults with only one study focusing on
infants52. Although it had been shown that premature infants can benefit
from MT87, there is still controversy regarding pain relief52.
Third, detection bias is a concern for individual trials. This is because
the pain is generally decreasing during the postoperative period. Given
the immediate effect of MT on alleviating postoperative pain, early
intervention with a suitable MT regimen would lead to the optimal
outcome. In addition, there are clinical studies on preoperative in­
terventions88, the results of which would allow interesting comparisons
between the preoperative and postoperative interventions.
Lastly, the effect of MT may depend on the practitioner89. Thus, the
qualification, experience, and clinical expertize of the practitioner are
likely to affect the results of clinical trials. In the included RCTs, the
practitioners were trained nurses, researchers, professional massage
therapists, and patients’ companions. However, there is no uniform
standard for evaluation of the skill level of MT practitioners. Therefore,
we recommend reporting the information of the practitioner in future
studies.

8
C. Liu et al.
8. Conclusions
Our systematic review showed that MT may be effective for post­
operative pain relief. We also found a high level of heterogeneity among
existing studies, most of which were compromised in the methodolog­
ical quality. Thus, more high-quality RCTs with a low risk of bias, longer
follow-up, and a sufficient sample size are needed to demonstrate the
true usefulness of MT.
5. Implications for further research
While different levels of applied pressure (e.g., mild, moderate, or
firm) were reported in some RCTs, the pressure level was not mentioned
in many others. Details on MT including the pressure, specific methods,
treatment sites, and the practitioner’s skill levels should be included and
explored in further studies. Our result on the different outcomes with
various types of surgeries also calls for further investigations of the
impact of surgery type on MT efficacy. These developments would lead
to the use of best MT approach for maximum pain relief after surgery.
Declaration of Competing Interest
All authors declare that they have no competing interest.
Acknowledgments
We thank Professor Chen and Dr. Zhao for their guidance and sup­
port on the search strategy. We would also like to express our gratitude
to researchers who performed RCTs and responded to our request for
data.
Ethical Approval
This article does notcontain any studies with human participants or
animals performed by any of theauthors.
Authors’ Contributions
All authors have made significant contributions to the formulation of
search strategies, literature retrieval and acquisition; Ms. Wu and Ms.
Liu independently completed the extraction, sorting and analysis of all
data throughout the research process; all authors gave final approval for
the version to be published and agreed to be responsible for all aspects of
the work.
Informed Consent
Informed consentwas waived due the retrospective nature of this
systematic review and meta-analysis.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.ctim.2022.102892.
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