Article

Massage therapy for people with HIV/AIDS

Centre for Allied Health Evidence, University of South Australia (City East), North Terrace, Adelaide, SA, Australia, 5000.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 01/2010; 1(1):CD007502. DOI: 10.1002/14651858.CD007502.pub2
Source: PubMed

ABSTRACT

People living with HIV/AIDS may experience a lower quality of life due to complications of the disease. Massage therapy may help people by improving their overall health and their ability to deal with stress. We systematically investigated studies that have compared massage therapy with other forms of therapy or no therapy. We found four randomised controled trials that used massage therapy with children, adolescents or adults with HIV or late-stage AIDS. This review of the literature supports that massage therapy can benefit people with HIV/AIDS by improving quality of life, particularly if they receive the therapy in conjunction with other techniques, such as meditation and relaxation training, and provide more benefit than any one of these techniques individually. Furthermore, it may be that massage therapy can improve their body's ability to fight the disease; however, this is not yet convincingly proven. We recommend further studies be undertaken to investigate this question and recommend that in the meantime, people with HIV/AIDS use massage therapy to improve quality of life, provided they have clear goals and monitor their response to the therapy.

Full-text

Available from: Sue Statham, Oct 05, 2015
Massage therapy for people with HIV/AIDS (Review)
Hillier SL, Louw Q, Morris L, Uwimana J, Statham S
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2010, Issue 1
http://www.thecochranelibrary.com
Massage therapy for people with HIV/AIDS (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Page 1
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20SOURCES O F SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iMassage therapy for people with H IV/AIDS (Review)
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[Intervention Review]
Massage therapy for people with HIV/AIDS
Susan L Hillier
1
, Quinette Louw
2
, Linzette Morris
2
, Jeanine Uwimana
3
, Sue Statham
2
1
Centre for Allied Health Evidence, University of South Australia (City East), Adelaide, Australia.
2
Faculty of Health Science, Stellen-
bosch University, Cape Town, South Africa.
3
Faculty of Health Science, University of Western Cape, Cape Town, South Africa
Contact address: Susan L Hillier, Centre for Allied Health Evidence, University of South Australia (City East), North Terrace, Adelaide,
SA, 5000, Australia.
Susan.Hillier@unisa.edu.au.
Editorial group: Cochrane HIV/AIDS Group.
Publication status and date: New, published in Issue 1, 2010.
Review content assessed as up-to-date: 2 November 2009.
Citation: Hillier SL, Louw Q, Morris L, Uwimana J, Statham S. Massage therapy for people with HIV/AIDS. Cochrane Database of
Systematic Reviews 2010, Issue 1. Art. No.: CD007502. DOI: 10.1002/14651858.CD007502.pub2.
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Infection with human immunodeficency virus (HIV) and acquired immunodeficency syndrome (AIDS) is a pandemic that has affected
millions of people globally. Although major research and clinical initiatives are addressing prevention and cure strategies, issues of
quality of life for survivors have received less attention. Massage therapy is proposed to have a positive effect on quality of life and may
also have a positive effect on immune function through stress mediation.
Objectives
The objective of this systematic review was to examine the safety and effectiveness of massage therapy on quality of life, pain and
immune system parameters in people living with HIV/AIDS.
Search methods
A comprehensive search strategy was devised incorporating appropriate terms for HIV/AIDS, randomised controlled trials (RCTs),
massage therapy and the pertinent measures of benefit. All electronic databases identified were search ed in November 2008, including
Cochrane Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, SCIENCE
CITATION INDEX, AIDSLINE, AIDSearch, CINAHL, HEALTHSTAR, PsycLIT, AMED, Current Contents, AMI, NLM GATE-
WAY, LILACS, IndMed, SOCIOFILE, SCI, SSCI, ERIC and DAI. We also reviewed rele vant published and unpublished conference
abstracts and proceedings and scrutinised reference lists from pe rtinent journals. There were no language or date restrictions.
Selection criteria
Studies were identified by two reviewers based on trial design (RCTs) and participants (ie, people of any age with HIV/AIDS, at any
stage of th e disease) who had undergone an intervention that included massage therapy for the identified aims of improving quality of
life and activity and participation levels, improving immune function, reducing pain and improving other physiological or psychological
impairments.
Data collection and analysis
Two reviewers independently identified included studies and extracted relevant data. Two other reviewers independently reviewed the
included studies for risk of bias. All data and risk of bias judgements were e ntered into Revman (v5) and me ta-analyses were conducted
where appropriate.
1Massage therapy for people with HIV/AIDS (Review)
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Main results
Twelve papers were identified, from which four were included. The remaining eight papers were excluded predominantly due to
inappropriate methodology. The four included studies were highly clinically heterogenous, investigating a range of age groups (ie,
children, adolescents and adults) across the disease spectrum from earl y HIV th r ough late-stage AIDS. The settings were either
community or palliative care, and the outcome measures were a combination of quality of life and immunological function. The trials
were judged to be at moderate r isk of bias mostly because of incomplete reporting. For quality of life measures, the studies reporte d that
massage therapy in combination with other modalities, such as meditation and stress reduction, are superior to massage therapy alone
or to the other modalities alone. The quality of life domains with significant effect sizes included self-reported reduced use of health
care resources, improvement in self-perceived spiritual quality of life and improvement in total quality of life scores. One study also
reported positive changes in immune function, in particular CD4+ cell count and natural killer cell counts, due to massage therapy,
and one study reported no difference between people given massage therapy and controls in immune parameters. Adverse or harmful
effects were not well reported.
Authors’ conclusions
There is some evidence to support the use of massage therapy to improve quality of life for people living with HIV/AIDS (PLWHA),
particularly in combination with other stress-management modalities, and that massage therapy may have a positive effect on immuno-
logical function. The trials are small , however, and at moderate risk of bias. Further studies are needed using larger sample sizes and
rigorous design/reporting before massage therapy can be strongly recommended for PLWHA.
P L A I N L A N G U A G E S U M M A R Y
Massage therapy for people with HIV/AIDS
People living with HIV/AIDS may experience a lower quality of life due to complications of the disease. Massage therapy may help
people by improving their overall health and their ability to deal with stress. We systematically investigated studies that have compared
massage therapy with other forms of therapy or no therapy. We found four randomised controled trials that used massage therapy with
children, adolescents or adults with HIV or late-stage AIDS. This review of the literature supports that massage therapy can benefit
people with HIV/AIDS by improving quality of life, particularly if they receive th e therapy in conjunction with othe r techniques, such
as meditation and relaxation training, and provide more benefit than any one of these techniques individually. Furthermore, it may be
that massage therapy can improve their body’s ability to fight the disease; however, this is not yet convincingly proven. We recommend
further studies be undertaken to investigate this question and recommend th at in the meantime, people with HIV/AIDS use massage
therapy to improve quality of life , provided they have clear goals and monitor their response to the ther apy.
B A C K G R O U N D
The human immunodeficency virus (HIV) and acquired immun-
odeficency syndrome (AIDS) is a pandemic that h as affected mil-
lions of people globally. The 2007 AIDS e pidemic update re-
port from the World Health Organization (WHO) and the Joint
United Nations Programme on HIV/AIDS (UNAIDS) highlights
an estimated 33 million people living with HIV/AIDS (PLWHA)
worldwide. More than two of three (68%) adults and nearly
90% of children infected with HIV live in sub-Saharan Africa
and more than three in four (76%) cases result in AIDS death
(
UNAIDS/WHO 2007). Effective prevention strategies and avail-
ability of antiretroviral therapy (ART) have had some effect on the
infection rate and number of deaths; however, AIDS remains a
leading cause of mortality worldwide (
UNAIDS 2008). Moreover,
the high HIV infection rate and lack of good treatment options
in some areas has clear negative affects on the quality of life of
PWHA, notwithstanding changes in mortality rates.
Description of the condition
The human immunodeficiency virus is a lentivirus, a member of
the retrovirus family that can lead to AIDS. The virus primarily
infects vital cells in the human immune system, such as helper T
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cells (specifically, CD4+ T cells), macrophages and dendritic cells.
Infection with HIV leads to low levels of CD4+ T cell s th r ough
three mechanisms: first by direct killing of infected cells; second,
by increased rates of apoptosis in infected cells; and third, by killing
infected CD4+ T cells by CD8 cytotoxic l ymphocytes that recog-
nise infected cells (
Lawn 2004). When CD4+ T cell numbers de-
cline below a critical level, cell-mediated immunity is lost and the
body becomes progressively more susceptible to opportunistic in-
fections. Eventually, most people with HIV develop AIDS. The
mortality from AIDS is due primarily due to OIs such as tubercu-
losis (TB) or malignancies associated with the progressive failure
of the immune system (
Lawn 2004).
The main symptoms reported by PLWHA include the OIs, night
sweats, fatigue, weight loss, Pneumocystis carinii pneumonia, Ka-
posis sarcoma, cytomegalovirus lymphadenitis, depression, anx-
iety, poor sleep quality and pain. Peripheral neuropathic or no-
ciceptive pain is a unique form of chronic pain that affects up
to 60% of PLWHA. In Rwanda, for example, pain is the most
prevalent symptom experienced by PLWHA (
Uwimana 2005).
The experience of these symptoms negatively affects physical abil-
ity and consequently reduces quality of life, as patients experience
limitations in their activities and partcipation (
Stjernswärd 2002,
Eastbrook 2001, Ownby 2006, Gray 2007). The clinical course
of HIV/AIDS is changing due to medical and pharmacological
discoveries, survival rates have increased and th e picture of the
disease is evolving as a chronic more than fatal condition.This
change brings to the fore questions of longer-term management
of symptoms, maintaining independence and quality of life for
some individuals, while for others palliative care is required for an
extended period.
Description of the intervent ion
The management of HIV/AIDS is usually in the form of pharma-
cological modalities, such as antiretroviral drugs, analgesic ther-
apy and other pharmacological agents, and non-pharmacologi-
cal modalities, such as massage, exercise and palliative care. The
essence of these non-pharmacological modalities in HIV manage-
ment is not intended to replace disease-modifying treatments such
as ART, but to augment the comfort and support of individuals
and families who are living with life-threatening illness. Therefore,
different techniques and interventions used in symptom manage-
ment, maintenance of independence and palliative care should be
further explored. Pain and consequent phy sical disability is re-
portedly often under-treated in PLWHA (
O’Neill 1993; Gwyther
2004
). Findings of a recent study conducted in Rwanda also high-
lighted that impaired quality of life due to pain and disability
was among the most unmet needs of PLWHA (
Uwimana 2007).
These findings signify the need to explore alternative intervention
strategies to enhance the quality of life of PLWHA. Physical in-
terventions, such as exercise, have been shown to be effective in
improving physical function and psychological status for PLWHA
(
O’Brien 2004). One systematic review (Harding 2005) highlights
that home palliative care and inpatient hospice care also signif-
icantly improved patient outcomes in the domains of pain and
symptom control, anxiety, insight and spiritual wel l-being.
Therapeutic massage is another promising non-pharmacological
intervention with reported benefits for PLWHA. The American
Massage Therapy Association defines massage as the application of
manual techniques and adjunctive therapies with the intention of
positively affecting the heath and well being of the client (
AMTA
2000
). Massage therapy can include specific physical techniques or
manual therapy, such as deep tissue work, Swedish massage, neu-
romuscular massage, shiatsu or acupressure (
Rich 2002). Massage
therapists generally hold certification or licensure to practice mas-
sage in those countries or jurisdictions where such qualifications
are recognized. Professional tr aining programs for massage thera-
pists also vary from country to country and may be undertaken as
part of a broader health professional training or as a profession in
its own right (
Rich 2002).
How the intervention might work
The reported effects of massage include pain relief, decreased levels
of depression, improved immune function, improved blood flow
and blood composition, reduced edema, and increased mobility
of connective tissue, muscle and the nervous system (Field 2005,
Goats 1994, Ironson 1996, Toups 1999). Massage is therefore po-
tentially effective in improving the quality of l ife in patients suffer-
ing from chronic disorders (
Muller-Oerlingausen 2007). Several
studies have indicated that there is an increase in immune func-
tion following massage (
Ironson 1996, Hernandez-Rief 2004).
The proposed mech anisms for this effect are via alterations in bio-
chemistry, such as reduced levels of cortisol and increased levels
of serotonin and dopamine (
Field 2005). What mediates these
biochemical effects is not known but presumed to occur through
stress reduction. With the myriad physical, psychological and bio-
chemical effects reported in the literature, it is plausible that mas-
sage therapy could be useful in PLWHA in its ability to reduce
symptoms such as pain and de pression, improve immune system
function and finally improve quality of life.
Why it is important to do this review
The prevalence of HIV/AIDS, and its catastrophic impact on the
health and quality of life of PLWHA, necessitates significant in-
vestigations into safe and effective management strategies. In par-
ticular, HIV/AIDS is rife in developing and low-income countries
where health budgets are small. Within this context an interven-
tion which is low cost and can be taught to care-givers and families
to administer holds great appeal. Massage has been identified as a
suitable, low-cost intervention in the context of developing coun-
tries (
Maul ik 2009). The aim of this systematic review, therefore,
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is to ascertain the effectiveness of massage therapy on quality of
life, pain and immune system function in PLWHA.
O B J E C T I V E S
To examine the safety and effectiveness of massage therapy on
quality of life, pain and immune system parameters in PLWHA
M E T H O D S
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs) comparing massage therapy
with no therapy or another therapy modality. Controlled clinical
trials (CCTs) were also considered if the re were insufficient high-
quality RCTs.
Types of participants
All studies which included children, adolescents and adults with a
diagnosis of HIV infection (all stages) were included. Studies of
males only, females only, or both genders were included.
Types of interventions
Massage therapy was de fined as systematic and scientific manip-
ulation of body tissues pe rformed with the hands of the therapist
for the purpose of affecting the nervous and muscular systems and
the general circulation, and was administered by a qualified health
professional. The comparisons of interest were massage therapy
compared to no therapy, sham or placebo therapy or another kind
of therapy, such as exercise or relaxation training.
Types of outcome measures
The outcome measures considered included immunological and
virological indicators and psychosocial measures.
Adverse events, including but not limited to injury, increased pain,
increased neuropathic symptoms and immune suppression also
were evaluated in included studies where reported.
Primary outcomes
The primary outcome measure was health-related quality of life
(for example, the WHOQoL or EuroQoL), general health ques-
tionnaires (for example, the SF-36) and measures of restrictions
of activity and participation.
Secondary outcomes
Secondary measures that were considered included:
Immunological and virological indicators, including CD4
cell count (cells/mm
3
) and viral load (log
10
copies),
Measures of impairment, including pain, stiffness, anxiety
and de pression scales
Othe r psychol ogical and physiological me asures not listed
above.
Search meth ods for identification of stud ies
A comprehensive HIV/AIDS and RCT search strategy was pro-
vided via consultation with the HIV/AIDS Trials Search Coordi-
nator (TSC) and was further refined.
Electronic searches
The following electronic databases were searche d using the estab-
lished keywords, with no date limits and no language restrictions.
Cochrane Group Trials Register
Cochrane Central Register of Controlled Trials (CENTRAL)
a) MEDLINE
b) EMBASE
c) SCIENCE CITATION INDEX
d) AIDSLINE, AIDSearch
e) CINAHL
f) HEALTHSTAR
g) PsycLIT
h) AMED
i) Current Contents
j) A MI
k) NLM GATEWAY
l) LILACS
m) IndMed
n) SOCIOFILE
l) SCI. SSCI. ERIC, DAI.
PubMed HIV Comprehensive Search Strategy
HIV string: HIV Infections[MeSH] OR HIV[MeSH] OR
HIV[tw] O R hiv-1*[tw] OR hiv-2*[tw] OR hiv1[tw] OR hiv2[tw]
OR HIV infect*[tw] OR human immunodeficiency virus[tw] OR
human immunedeficiency virus[tw] OR human immuno-defi-
ciency virus[tw] OR human immune-deficiency virus[tw] OR
((human immun*) AND (deficiency virus[tw])) OR acquired im-
munodeficiency syndrome[tw] OR acquired immunedeficiency
syndrome[tw] OR acquired immuno-deficiency syndrome[tw]
OR acquired immune-deficiency syndrome[tw] OR ((acquired
immun*) AND (deficiency syndrome[tw])) OR sexually trans-
mitted diseases, viral”[MH]
Anti HIV string: Antiretroviral Therapy, Highly Active”[MeSH]
OR Anti-
Retroviral Agents”[MeSH] OR Antiviral Agents”[MeSH:NoExp]
OR ((anti) AND (HIV[tw])) OR antiretroviral*[tw] OR ((anti)
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AND (retroviral *[tw])) OR HAART[tw] OR ((anti) AND (ac-
quired immunodeficiency[tw])) OR ((anti) AND (acquired im-
munedeficiency[tw])) OR ((anti) AND (acquired immuno-defi-
ciency[tw])) OR ((anti) AND (acquired immune-deficiency[tw]))
OR ((anti) AND (acquired immun*) AND (deficiency[tw]))
RCT Search strategy: (randomized controlled trial [pt] OR con-
trolled clinical trial [pt] OR randomized controlled trials [mh]
OR random allocation [mh] OR double-blind method [mh] OR
single-blind method [mh] OR clinical trial [pt] OR clinical trials
[mh] OR (“cl inical trial” [tw]) OR ((singl* [tw] OR doubl* [tw]
OR trebl* [tw] OR tripl* [tw]) AND (mask* [tw] OR blind* [tw]))
OR (placebos [mh] OR placebo* [tw] OR random* [tw] OR re-
search design [mh:noexp] OR (comparative study) OR (compar-
ative studies) OR (evaluation studies) OR (evaluation study) OR
follow-up studies [mh] OR pr ospective studies [mh] OR control*
[tw] OR prospectiv* [tw] O R volunteer* [tw])) NOT (animals
[mh] NOT human [mh])
When using the above strategies in other databases the following
were removed: [pt] ; [mh] ; [tw] ; [MeSH;NoEXP]
Examples of specific keywords used were: massage”, massage
therapy”, quality of life”, “pain”.
Searching other resources
The reference lists of all studies were checked.
Authors of significant papers were contacted to find other relevant
published or unpublished studies.
The following online registers of ongoing trials on HIV and AIDS
were searched:
http://controlled-trials.com
http://clinicaltrials.gov
A search for conference proceedings from relevantHIV/AIDS con-
ferences and unpublished theses was undertaken.
Data c ollection and analysis
Where differences arose between the two reviewers in their deter-
mination of study inclusion, data extraction or quality evaluation,
a third reviewer was consulted and consensus was reached via dis-
cussion.
Selection of studies
Two reviewers checked the studies identified by keyword search
independently, by reading the abstracts to see if they met the inclu-
sion criteria. All disagreements were resolved by consensus. If all
the criteria were met, the study was retrieved in full and reviewed
for methodological quality (risk of bias) and data extraction.
Data extraction and management
Data were entered into Revman (version 5) independently by two
reviewers. Data included full citation details of the study, objec-
tives, design, length, assessment time points, number and charac-
teristics of participants (inclusion and e xclusion criteria), de scrip-
tion of intervention, outcome measures, withdrawals and adverse
events.
Assessment of risk of bias in included studies
Two reviewers independently assessed the quality of the included
studies for risk of bias using criteria recommended in the Cochrane
Reviewers Handbook (Higgins and Green 2008, version 5, section
8) in four domains: sequence generation, al location concealment,
blinding of participants, personnel and outcome assessors, and
incomplete outcome data (Table 8.5a). Studies were given an
overall summary of th e risk of bias for each important outcome
across domains, as well as within and across studies using three
levels: low, unclear or high risk of bias (Table 8.7a). The overall
risk of bias was reported narratively in the context of any findings
produced from a meta-analysis. Any conflict in evaluating risk was
discussed with a third reviewer and consensus was reached.
Measures of treatment effect
Data were extracted and analysed to calculate relative risk, 95%
confidence intervals and individual and group effect sizes. This
required the identification of the number of participants in each
group in each trial and total number for dichotomous data and
the number of participants plus the mean and standard deviations
for each group for continuous data.
Unit of analysis issues
Studies with non-standard designs were considered; for example,
cluster randomised trials were included if they were assessed as
having a low risk of bias. Cross-over trials were considered only if
they included an adequate washout period between phases or the
authors provided an analysis of results for the first phase (ie, prior
to cross-over).
Dealing with missing data
Authors were contacted to provide appropriate data for meta-anal-
ysis if these were not adequately reported in the retrieved paper.
Intention to treat analysis was considered as part of the risk of bias
assessment and loss to follow up was recorded.
Assessment of heterogeneity
Statistical heterogeneity was assessed visually and using the I
2
statistic.
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Clinical heterogeneity (clinical and methodological diversity) was
evaluated by th e content experts on the review team.
Assessment of reporting biases
Reporting biases were avoided in part by the comprehensive search
strategies and by having no date or language limits.
Data synthesis
Where possible, a meta-analysis was conducted with data using
random effects, as the heterogeneity was expected to be relatively
high. Where data were not available or were of e xcessive hetero-
geneity, a narrative summary of study results rather than a meta-
analysis was produced.
Subgroup analysis a nd investigation of heterogeneity
If possible, sub-group analyses were to be performed to establish
effectiveness among different groups (eg, males vs. females, chil-
dren vs. adults or symptomatic vs. asymptomatic); however, there
were insufficient studies to enable this.
Sensitivity analysis
Sensitivity analyses may have been conducted to determine if par-
ticular studies skewed results where possible (eg, RCT vs. non-
RCTs); however, this was not necessary.
R E S U L T S
Description of studies
See:
Characteristics of included studies; Characteristics of excluded
studies.
Results of the search
The search strategy resulted in 322 citations. The titles and ab-
stracts were reviewed against the inclusion criteria, resulting in 12
full articles being retrieved.
Included studies
The12 retrieved citations were reviewed by two reviewers and sub-
sequently four studies were agreed on for final inclusion (
Birk
2000
, Diego 2001, Shor-Posner 2006, Williams 2005). Two pa-
pers by Shor-Posner (Shor-Posner 2004 and Shor-Posner 2006)
were retrieved but were found to report on the same trial so that
only the latter, with the full outcome data, was included (see ’Char-
acteristics of included studies table ).
Design
All four included studies were RCTs--two trials with two interven-
tion arms and two trials with four. All studies included a control
group that received usual or standard care that did not contain
the intervention under investigation (
Birk 2000, Williams 2005);
a placebo intervention of friendly visits (
Shor-Posner 2006) or an
alternate plausible intervention of progressive muscular relaxation
(
Diego 2001).
Participants
Sample sizes ranged from 24 to 58 with a total of 178 participants
across the four studies. The participants were adults (age range 27-
50 years) in two studies (
Birk 2000, Williams 2005), adolescents
(aged 13-19 years) in one study (
Diego 2001), or children (aged 2-
8 years) in
Shor-Posner 2006. Three studies investigated PLWHA
who were diagnosed as infected with HIV but with no AIDS
symptoms and non-hospitalised, and the fourth (
Williams 2005)
investigated people in late-stage AIDS.
Setting
Three studies were conducted in a community or home setting
and one study (
Williams 2005) was conducted in an AIDS-specific
nursing facility. All studies were conducted in the United States
except for
Shor-Posner 2006, where the researchers were from the
United States, but the actual participants resided in the Dominican
Republic.
Interventions
All tr ials included one arm with massage therapy alone. This was
administered for 12 weeks in three trials and four weeks in the
fourth trial (Williams 2005), with an intensity of one, two or five
times a week. Individual sessions ranged from 20 to 45 minutes.
The massage techniques were variously described to include the
upper or whole body and addressed major muscle groups for essen-
tially relaxation responses (Swedish style). The studies all utilised
trained massage therapists/health professionals.
The trials with greater than two arms investigated the effect of
massage therapy alone and in combination with other modalities,
such as aerobic exercise, biofeedback stress reduction (Birk 2000)
and meditation (
Williams 2005).
Outcomes
Two studies included quality of life measures (
Birk 2000, Williams
2005), although only one (Diego 2001) included psychological
measures for anxiety and depression.
Birk 2000 measured health
care utilisation and health per ception as part of the quality of life
measures. Three studies included physiological measures of dis-
ease, including CD4, CD8 and natural killer cell counts. No stud-
ies investigated pain, activity or participation restrictions, impair-
ments or viral load.
Excluded studies
Seven studies were excluded, predominantly due to trial method-
6Massage therapy for people with HIV/AIDS (Review)
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ology issues. Three were of low design quality with no control
group or were case ser ies only or were secondary research papers:
two were systematic reviews, one was a non-systematic review and
one was a descriptive study. See table of Ch aracteristics of e xcluded
studies.
Risk of bias in included studies
The risk of bias across the four included studies was judged to
be moderate, primarily due to unclear, unreported or negative re-
sponses. The judgements overall f or the studies and for individ-
ual items in the individual studies are illustrated in
Figure 1 and
Figure 2, respectively. Attempts to clarify missing or unclear infor-
mation from the study authors were made, but only one author
responded.
Figure 1. Risk of bias graph: reviewers’ judgements about each risk of bias item presented as percentages
across all included studies.
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Figure 2. Risk of bias summary: reviewers’ judgements about each item for each included study.
Allocation
Only two studies used adequate sequence generation (Diego 2001,
confirmed via author contact, and
Williams 2005). In the remain-
ing studies the sequence generation process was not mentioned or
was not clear. None of the studies reported that the allocation to
the groups was concealed.
Blinding
Williams 2005 reported blinding of the assessors, and for Shor-
Posner 2006 it may be deduced that as the data were analysed in
a laboratory by a machine, blinding of the assessor may have been
implemented.
Diego 2001 confirmed that the researchers con-
ducting the assessments and blood assays were blinded. No studies
blinded the subjects or therapists, or reported doing so; th is is an
expected finding because the nature of the physical intervention
of massage cannot be concealed from the provider or the receiver,
although the intent may be.
Incomplete outcome data
Incomplete data outcomes were inadequately addressed or unclear
in all of the included studies, except for
Diego 2001, which had no
participants lost to the study.
Williams 2005 had a disproportional
loss to follow-up, but did, however, conduct intention-to-treat
analysis and reported on the nature of the subjects who failed to
complete.
Shor-Posner 2006 did not report how it dealt with loss
to foll ow-up.
Selective reporting
All studies were free of selective reporting.
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Other potential sources of bias
Two studies (
Williams 2005; Shor-Posner 2006) were considered
free of other bias because they adequately reported on the baseline
characteristics of the groups and the design of the study was ap-
propriate.
Diego 2001 confirmed that the study groups were not
different at baseline. Birk 2000 did not compare baseline charac-
teristics of groups.
Effects of interventions
Primary measures
Quality of life: In the two trials which investigated the primary
outcome measure of quality of life, massage therapy in combina-
tion with other modalities, such as biofeedback stress reduction
(
Birk 2000) and meditation (Williams 2005) was reported to be
superior to massage therapy alone, the other modalities alone or
the control groups. The superior effects were demonstrated in self-
reported improvement in quality of life (P=0.005 for total qual-
ity of life score and P=0.01 for spiritual scores, Williams 2005),
health perceptions and reducing h ealth care utilisation (P<0.05,
Birk 2000). Effect size calculations for each outcome (SMD, ran-
dom effects) produced significant results for transcendent (spiri-
tual) and total quality of life scores (both P<0.00001) and health
care utilisation (P=0.04) in favour of massage therapy but not for
health perception (P=0.19) (Figure 3). The overall effect for the
QoL scores was significant (P=0.007) but the pooled results are
inconclusive because heterogeneity was unacceptable at I
2
=89%.
Figure 3. Forest plot of comparison: MT vs control, outcome: Quality of life - mixed.
Activity and participation: No studies reported activity or partic-
ipation outcome measures.
Secondary measures
Immunological function: In the three trials which investigated the
effect of massage therapy on immunological function, massage
therapy was reported to be superior in improving some immuno-
logical functions, for example increased number and markers of
natural killer cells (P<0.01); increased CD4 cell count (P<0.05)
(
Diego 2001), and, in Shor-Posner 2006, more of the placebo
group had a decline in CD4 cell count (P=0.03), older children
receiving massage therapy had increased CD4+ (P=0.04), and
younger children with massage therapy had increased natural killer
cell count (P=0.05). The third trial (Birk 2000) did not show any
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significant differences between massage therapy and other modal-
ities on immune function. Where appropriate data were able to
be obtained, forest plots were constructed for CD4+ and natural
killer cell counts, whether massage therapy was administered alone
or in combination (Figure 4 and Figure 5). Meta-analysis using
the available data from
Birk 2000 was not appropriate due to the
skewed nature of the data - transformation of the means and SD
was not possible.
Figure 4. Forest plot of comparison: MT vs control, outcome: CD4 count (cells/ml).
Figure 5. Forest plot of comparison: MT vs control, outcome: Natural killer cell count per mm3.
Pain or musculoskeletal impairments: No studies reported on these
measures.
Anxiety and depression: Only one study (
Diego 2001) investi-
gated anxiety and depression levels and reported a significant pos-
itive effect of massage therapy compared with other modalities in
reducing depression (P<0.05). Data were not available for the cal-
culation of effect sizes.
Adverse events: Only one study (
Williams 2005) explicitly stated
that no adverse events were recorded. Adverse effects or harm were
not mentioned in the other three studies.
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D I S C U S S I O N
Summary of main results
Four trials were included in the review. Considering individual
domains of quality of l ife, there were findings in favour of massage
therapy in combination with other modalities,such as meditation
and stress reduction, being superior to massage therapy alone or
to the other modalities alone. The domains with significant ef-
fect sizes included a self-reported reduced use of health care re-
sources, improvement in self-pe r ceived spiritual quality of life and
an overall improvement in total quality of l ife scores. These find-
ings, however, were across two studies only. Individual studies al so
reported changes in immune function (in particular CD4+ and
natural killer cell counts) in favour of massage therapy, and one
study reported no difference between participants given massage
therapy and controls; however, the effect sizes failed to reach sig-
nificance (ie, were unable to be reasonably calculated).
Overall completeness and applicability of
evidence
The small number of trials located and the small number of par-
ticipants in each trial make any strong conclusions difficult. The
pooled data for all domains of quality of life, although reaching
significance, are difficult to interpret because the level of statisti-
cal heterogeneity was unacceptably high. There also was a high
level of clinical heterogeneity among the studies in terms of age
groups (children, adolescents and adults), stages of HIV/AIDS
(early HIV and late-stage AIDS), intensity or dosage of massage
therapy (from four weeks to 12 weeks and from one to five times
per week) and outcomes measures (differing quality of life mea-
sures and tests of immune function). Incomplete data sets, despite
contacting authors for completion, also hampered summary anal-
yses. The small number of trials and participants precluded any
sensitivity or sub-group analyses to evaluate the differential effects
of these variables.The skewed nature of the CD4 and natural killer
cell counts made those data inconcl usive because transformation
was not possible before meta-analysis. Three of the four studies
were conducted in the United States, which fur ther limits the ap-
plicability of study findings to other countries. Therefore, overall
there is some evidence for effectiveness but spread across a broad
range of age groups and HIV/AIDS stages and for a range of ben-
efits.
Quality of the evidence
Overall, the trials were appraised to be at moderate risk of bias.
All categories of bias were acceptable f or the majority of studies
(13 of a possible 24 items across the four studies were judged to
be low risk of bias), except for all ocation concealment, which was
not undertaken or not reported in all studies.
Potential biases in the review process
No potential biases were encountered in the review process.
Agreements and disagreements with other
studies or reviews
The overall findings of this review reflect the general conclusions
of most other studies: there appears to be a positive effect on the
quality of life of PLWHA particularly when massage therapy is de-
livered as a package of care, and that there is limited and conflict-
ing evidence about the effect of massage therapy on immunologi-
cal status. There are no other systematic reviews solely of massage
therapy for PLWHA and the extant literature has mainly consisted
of small studies of low methodological quality.
Two systematic reviews have evaluated complementary th erapies,
of which massage therapy is considered a part, in relation to effects
on PLWHA (
Ozsoy 1999, Mills 2005). Both studies also reported
that, despite the widespread use of complementary and alter native
medicine (CAM) by PLWHA, there is a paucity of clinical trials
and a low level of methodological quality. Both reviews found
more evidence for the use of CAM in the ’care’ rather than ’cure of
HIV/AIDS, meaning that the overall ef fect of CAM and therefore
also of massage therapy, may lie mostly in improving quality of life.
One (non-systematic) review article (
Field 2005) concluded that
massage therapy does have physiological stress-reduction effects for
a broad spectrum of people by decreasing cortisol and increasing
serotonin and dopamine.
In summary, the findings of this review are in agreement with
other related studies in the literature.
A U T H O R S C O N C L U S I O N S
Implications for practice
Massage therapy may be recommended for PLWHA with low to
moderate evidence to support its effectiveness in improving aspects
of quality of life, in early and late stages, and for different age
groups. Effectiveness appears to improve when massage therapy
is combined with other modalities, such as meditation and stress
management. It may be that the effects of massage therapy on
relaxation responses are short lived and that combining it with
other methods that promote long-term stress management offer
the most benefits. Clear, appropriate and globally standardised
outcome measures should be implemented to gauge the effect
of massage therapy given the low to moderate level of evidence.
The implications for policy-makers are that services which are
multi-facetted to include massage therapy should be encouraged
if e xpl icitly monitored.
There is mixed evidence to support the use of massage therapy to
improve immune function in PLWHA.
11Massage therapy for people with HIV/AIDS (Review)
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Page 13
There is as yet no evidence to support the use of massage therapy
to improve activity and participation l evels or to reduce pain in
PLWHA.
There is only limited evidence that massage therapy has no adverse
or harmful effects.
Implications for research
Future trials investigating massage therapy alone and in conjunc-
tion with other modalities are warranted.
Such trials need to:
Have sufficient power (participant numbers) to detect
meaningful effects
Employ rigorous methodology to reduce risk of bias; in
particular, trials need to implement adequate randomisation
processes, allocation concealment and account for loss to follow
up
Use measures of effects that are more universal to allow for
meta-analysis and cover a range of domains from physiological
through impairment, activity/participation levels and quality of
life
Incorporate participant satisfaction measures and explicit
recording of adverse events
Clearly establish the stage of HIV/AIDS of participants and
therefore investigate at which stage or stages massage therapy is
most effective
Investigate aspects of dosage/intensity/timing/type of the
massage therapy intervention
Investigate massage therapy in combination with other
modalities to ascertain packages of care
Analyse the cost-effectiveness of massage therapy and
Investigate the feasibility and effectiveness of massage
therapy in developing countries, where HIV/AIDS is highly
prevalent and where cultural beliefs and practices may have an
influence.
A C K N O W L E D G E M E N T S
The authors wish to acknowledge staff from the South Africa
Cochrane Centre and Professor Jean Nachega (Stellenbosch Uni-
versity) for expert advice during the review process.
R E F E R E N C E S
References to studies included in this review
Birk 2000 {published data only}
Birk T, McGrady A, MacArthur R, Khuder S. The effects
of massage therapy alone and in combination with other
complementar y therapies on immune system measures and
quality of life in Human Immunodeficiency Virus. The
Journal of Alternative and Complementary Medicine 2000;6
(5):405–414.
Diego 2001 {published data only}
Diego M, Field T, Hernandez-Reif M, Shaw K, Friedman
L, Ironson G. HIV adolescents show improved immune
function following mass a ge therapy. Intern J Neuroscience
2001;106:35–45.
Shor-Posner 2006 {published data only}
Shor-Posner G, Hernandez-reif M, Miguez M, Fletcher
M, Quintero N, Baez J, Perez-then E, Soto S, Mendoza R,
Castillo R, Zhang G. Impact of a Massage therapy clinical
trial on immune status in young Dominican children
infected with HIV-1. The Journal of Alternative and
Complementary Medicine 2006;12(6):511–516.
Williams 2005 {published data only}
Williams A, Selwyn P, Liberti L, Molde S, Njike V,
McCorkle R, Zelterman D, Katz D. A randomized
controlled trial of meditation and massage effects on quality
of life in people with late-stage disease: a pilot study. Journal
of Palliative Medicine 2005;8(5):939–953.
References to studies excluded from this review
Field 2005 {published data only}
Field T, Hernandez-Riez M, Diego M, Schanberg S, Kuhn
C. Cortisol decreases and serotonin increases following
massage therapy. Journal of Neuroscience 2005;115:
1397–1413.
Gore-Felton 2003 {published data only}
Gore-Felton C, Vosvick M, Power R, Koopman C, Ashton
E, Bachmann M, Israelski D, Spiegel D. Alternative
therapies: A common practice among men and women
living with HIV. Journal of the Association of Nurses in AIDS
Care 2003;14:17–27.
Henrikson 2001 {published data only}
Henrickson M. Clinical outcomes and patient perceptions
of acupuncture and/or massage therapies in HIV-infected
individuals. AIDS Care 2001;13:743–748.
Ironson 1996 {published data only}
Ironson G, Field T, Scafidi F, Hashimoto M, Kumar A,
Patarca R, Fletcher MA, Price A, Gonclaves A, Burman I,
Tetenman C. Mass a ge is associated with the enhancement
of the immune systemss cytotoxic capacity. International
Journal of Neuroscience 1996;84:205–217.
12Massage therapy for people with HIV/AIDS (Review)
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Page 14
Mills 2005 {published data only}
Mills E, Wu P, Ernst E. Complementary therapies for the
treatment of HIV: in search of the evidence. International
Journal of STD and AIDS 2005;16:395–402.
Ownby 2006 {published data only}
Ownby KK. Effects of ice massage on neuropathic pain in
persons with AIDS. Journal of Association of Nurses AIDS
Care 2006;17:15–22.
Ozsoy 1999 {published data only}
Ozsoy M, E rnst E. How effective are complementary
therapies for HIV and AIDS? A systematic review.
International Journal of STD and AIDS 1999;10:629–635.
Additional references
AMTA 2000
American Massage Therapy Association. Glossary of terms.
http://www.amtamassage.org/about/terms.html accessed
August 2008.
Birk 2000
Birk TJ, McGrady A, MacArthur RD, Khuder S. The
effects of massage alone and in combination with other
complementar y therapies on immune system measures and
quality of life in human immunodeficiency virus. Journal of
Alter Complement Med 2000;6 (5):405–414.
Diego 2001
Diego MA, Field T, Hernandez-Reif M, Shaw K, Friedman
L, Ironson G. HIV adolescents show improved immune
function following massage therapy. International Journal of
Neuroscience 2001;106: 35–45.
Eastbrook 2001
Eastbrook P, Meadway J. The changing epidemiology of
HIV infection: new challenges for HIV palliative care.
Journal of Royal Society of Medicine 2001;24:442–448.
Field 2005
Field T, Hernandez-Riez M, Diego M, Schanberg S, Kuhn
C. Cortisol decreases and serotonin and dopamine increase
following massage therapy. Journal of Neuroscience 2005;
115:1397–1413.
Goats 1994
Goats GC. Massage- the scientific basis of an ancient art.
Part 2 Physiological and therapeutic effects. British Journal
of Sports Medicine 1994;28 (3):153–156.
Gray 2007
Gray G, Berger P. Pain in women with HIV/AIDS. Pain
2007;Nov Suppl 1:13–21.
Gwyther 2004
Gwyther L, Rawlinson F. Symptom control in palliative
care: essential for quality of life. South Africa Medical
Journal 2004;94 (6):437–454.
Harding 2005
Harding R, Karus D, Easterbrooks P, Raveis VH, Higginson
IJ, Marconi K. Does palliative care improve outcomes
for patients with HIV/AIDS? A systematic review of the
evidence. Sexually Transmitted Infection 2005;81:2–3.
Hernandez-Rief 2004
Hernandez-Rief M, Ironson G, Field T. breast cancer
patients have improved immune and neuroendocrine
functions following massage therapy. Journal of
Psychosomatic Research 2004;57:45–52.
Ironson 1996
Ironson G, Field T, Scafidi F, Hashimoto M, Kumar A,
Patarca R, Fletcher MA, Price A, Gonclaves A, Burman I,
Tetenman C. Mass a ge is associated with the enhancement
of the immune systemss cytotoxic capacity. International
Journal of Neuroscience 1996;84:205–217.
Lawn 2004
Lawn SD. AI DS in Africa: the impact of coinfection on
the pathogenesis of HIV-1 infection. Journal of Infectious
Diseases 2004;48:1–12.
Maulik 2009
Maulik PK, Darmstadt GL. Community-based
interventions to optimise early childhood development
in low resource settings . Journal of Perinatology 2009;29:
531–542.
Muller-Oerlingausen 2007
Muller-Oerlingausen, B, Berg, C, Groll, W. The efficacy of
slow stroke massage in depression. Psychiatr Prax 2007;34
Suppl 3:S305–308.
O’Brien 2004
O’Brien, K, Nixon, S, Glazier, R.H, Tynan, A.M.
Progressive resistive exercise interventions for adults living
with HIV/AIDS. Cochrane Database of Systematic Reviews
2004, Issue 4.[Art. No.: CD004248. DOI: 10.1002/
14651858.CD004248.pub2]
O’Neill 1993
ONeill W, Sherrard J. Pain in human immunodeficiency
virus disease: A review. Journal of Pain 1993;54:3–14.
Ownby 2006
Ownby KK. Effects of ice massage on neuropathic pain in
persons with AIDS. Journal of Association of Nurses AIDS
Care 2006;17:15–22.
Rich 2002
Rich GJ. Massage therapy:The evidence for practice. 1st
Edition. Philadelphia: Elsevier, 2002.
Shor-Posner 2004
Shor-Posner G, Miguez M-J, Hernandez-Reif M, Perez-
Then E, Fletcher M. Massage Treatment on HIV-1 infected
Dominican children: A preliminary report on the efficacy
of massage therapy to preserve the immune system in
children without anti-retroviral medication. The Journal
of Alternative and Complementary Medicine 2004;10:
1093–1095.
Stjernswärd 2002
Stjernswärd J. Uganda: Initiating a government public
health approach to pain relief and palliative care. Journal of
Pain and Symptom Management 2002;24 (2):257–264.
Toups 1999
Toups DM. A healing touch: massage and HIV/AIDS.
STEP Perspect 1999;99(3):3–4.
13Massage therapy for people with HIV/AIDS (Review)
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Page 15
UNAIDS 2008
UNAIDS. Report on the global HI V/AIDS
epidemic 2008: executive summary.. http:
//data.unaids.org/pub/GlobalReport/2008/
JC1511˙GR08˙ExecutiveSummary˙en.pdf 2008.
UNAIDS/WHO 2007
UNAIDS/WHO. AIDS Epidemic Update Report
2007. http://data.unaids.org/pub/EPISlides/2007/
2007˙epiupdate˙en.pdf.
Uwimana 2005
Uwimana J, Struthers P. Met and unmet palliative care needs
of people living with HIV/AIDS in Rwanda. Masters thesis.
Physiotherapy Department, University of the Western
Cape, South Africa.
Uwimana 2007
Uwimana J, Struthers P. Met and unmet palliative care
needs of people living with HIV/AIDS in Rwanda. Journal
of Social Aspects of HIV/AIDS 2007;4(1):575–587.
Indicates the major publication for the study
14Massage therapy for people with HIV/AIDS (Review)
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C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Birk 2000
Methods RCT (4 groups)
MT vs. MT+ XS vs. MT+ BFB vs. control
Participants 42 male and female adults (27-50); HIV+, no AIDS symptoms; non-hospitalised
Interventions Group 1: MT 12/52 1xpw for 45 min (Swedish type, whole body) n=8
Group 2: MT a/a plus aerobic exercise (supervised 2x pw) n=7
Group 3: MT a/a plus biofeedback stress reduction 1xpw n=8
Group 4: Control - standard care (no MT) n=8
Outcomes 6D QoL; CD4, CD8 and NKC counts; CD4/8 ratio.
Notes MT+BFB favourably increases health perceptions and reduces health care utilisation (p<0.05),
compared to single/other modalities or control. No other significant findings
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? No Sequence generation was not specified.
Allocation concealment? No Not reported
Blinding?
All outcomes
No Not reported
Free of selective reporting? Yes
Free of other bias? No Baseline comparison between groups not done.
Diego 2001
Methods RCT (2 groups)
MT vs. other
Participants 24 male and female adolescents (13-19); HIV+, no AIDS symptoms; outpatients
Interventions Group 1: MT 12/52 2xpw for 20min (upper body in chair) n=12
Group 2: Other - 12/52 progressive muscular relaxation 2xpw n=12
Outcomes STAI (anxiety); CES-D (depression); CD4, CD8 and NKC counts; CD4/8 ratio
15Massage therapy for people with HIV/AIDS (Review)
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Diego 2001 (Continued)
Notes MT reduced depression (p<0.05); increased NKC number and marker (p<0.01); in-
creased CD4 (p<0.05) compared to othe r modality
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? Yes Sequence generation relayed via email
Allocation concealment? No Not reported or relayed via email
Blinding?
All outcomes
Yes Of assessors
Incomplete outcome data addressed?
All outcomes
Yes living with HIV/AIDS. Cochrane Database of System-
atic Reviews 2004,
Free of selective reporting? Yes Most likely
Free of other bias? Yes Baseline characteristics for groups did not differ
Shor-Posner 2006
Methods RCT
MT vs. placebo
Participants 54 male and female children (2-8); HIV+, no AIDs symptoms; non-hospitalised
Interventions Group 1: MT 12/52 2xpw for 20 min (various body areas) n=22
Group 2: placebo - friendly visit 2xpw for 20 min n=25
Outcomes CD4, CD8 and NKC counts.
Notes More of pl acebo had decline in CD4 count (p=0.03); older children with MT had
increased CD4+ (p=0.04); younger children with MT had increased NKC (p=0.05)
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? No Sequence generation not stated.
Allocation concealment? No Not reported
Blinding?
All outcomes
Yes Assessor may have been blinded as data were analysed in a lab-
oratory and conducted by a machine
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Shor-Posner 2006 (Continued)
Incomplete outcome data addressed?
All outcomes
No Authors did not mention how they dealt with loss to follow-up
Free of selective reporting? Yes
Free of other bias? Yes
Williams 2005
Methods RCT
MT vs. MT+ meditation vs. meditation vs. control
Participants 58 male and female adults; late stage AIDS with/out co-morbidities; hospitalised
Interventions Group 1: meditation 4/52; n=13
Group 2: MT 4/52 5xpw for 30 min (various body areas) n=16
Group 3: meditation a/a plus MT a/a n=13
Group 4: control - standard care (no MT or meditation) n=16
Outcomes QoL - total score and spiritual sub-category.
Notes MT+ meditation superior to single modalities/control for improved QoL-transcendent
and QoL-total scores (p=0.01 and p=0.005 respectively)
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? Yes
Allocation concealment? No Not reported
Blinding?
All outcomes
Yes mentioned that assessor was blinded
Incomplete outcome data addressed?
All outcomes
Unclear Although intention-to-treat analysis was
conducted, there was a disproportionate
loss to follow-up
references
Data and analyses 1 MT vs control
Free of selective reporting? Yes
Free of other bias? Yes
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Page 19
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Field 2005 Methodology - review (non-systematic)
Gore-Felton 2003 Methodology - descriptive only
Henrikson 2001 Methodology - case control , quasi-experimental
Ironson 1996 Methodology - no control group
Mills 2005 Methodology - systematic review
Ownby 2006 Methodology - repeated measures, n=1 design
Ozsoy 1999 Methodology - systematic review
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D A T A A N D A N A L Y S E S
Comparison 1. MT vs control
Outcome or subgroup title
No. of
studies
No. of
participants
Statistical method Effect size
1 Quality of life 2 90 Std. Mean Difference (IV, Random, 95% CI) 2.43 [0.67, 4.18]
1.1 QoL - Health perception 1 16 Std. Mean Difference (IV, Random, 95% CI) 0.67 [-0.34, 1.69]
1.2 QoL - Health care
utilisation
1 16 Std. Mean Difference (IV, Random, 95% CI) 1.15 [0.07, 2.23]
1.3 QoL - Transcendent 1 29 Std. Mean Difference (IV, Random, 95% CI) 4.16 [2.79, 5.52]
1.4 QoL - Total score 1 29 Std. Mean Difference (IV, Random, 95% CI) 3.91 [2.60, 5.21]
3 CD4 count (cells/ml) 2 71 Std. Mean Difference (IV, Random, 95% CI) -0.23 [-0.70, 0.24]
3.1 MT plus other vs. control 1 31 Std. Mean Difference (IV, Random, 95% CI) -0.31 [-1.02, 0.40]
3.2 MT alone vs. control 2 40 Std. Mean Difference (IV, Random, 95% CI) -0.20 [-1.01, 0.61]
4 Natural killer cell count 2 40 Std. Mean Difference (IV, Random, 95% CI) 0.52 [-0.11, 1.15]
H I S T O R Y
Protocol first published: Issue 4, 2008
Review first published: Issue 1, 2010
Date Event Description
3 November 2009 Feedback has been incorporated Authors have added information in response to reviewers feedback. Ready
for final approval
C O N T R I B U T I O N S O F A U T H O R S
Each author contributed specific sections of the review. Uwimana and Statham have content and clinical experience and contributed
to the background, overall findings, and clinical content decision making. Hillier, Louw and Morris have experience in the conduct of
systematic reviews and performed the process aspects of the review.
19Massage therapy for people with HIV/AIDS (Review)
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Page 21
D E C L A R A T I O N S O F I N T E R E S T
There are no known conflicts of interest.
S O U R C E S O F S U P P O R T
Internal sources
Nil, Not specified.
External sources
Nil, Not specified.
I N D E X T E R M S
Medical Subject Headings (MeSH)
Massage;
Quality of Life; Acquired Immunodeficiency Syndrome [psychology; rehabilitation]; CD4-Positive T-Lymphocytes; HIV
Infections [immunology; psychology;
rehabilitation]; HIV-1; Randomized Controlled Trials as Topic
MeSH check words
Adolescent; Adult; Child; Humans
20Massage therapy for people with HIV/AIDS (Review)
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    • "In fact, patients were likely to use conventional parameters such as CD4-counts to make their decisions [31]. There is some evidence that CT can benefit PLWHA, namely exercise [32], stress-management [33,34] and massage [35]. This case study provides a description of an NW London community multi-agency service and explores its impact, in particular the CT provision, for both staff and clients. "
    [Show abstract] [Hide abstract] ABSTRACT: To present a case study of complementary therapy (CT) provision within a community HIV multi-agency service in a Northwest London deprived area. Anonymised routine service data were provided for all clients (n = 1030) August 2010 to October 2012. Face-to-face meetings provided feedback from volunteers (9 CT-using clients and 9 staff). CT-users were demographically similar to other clients. Support for coping with HIV was commonly cited as a service benefit. Over 26 months 1416 CT sessions were provided; 875 aromatherapy and 471 shiatsu. CT-users' most common concerns were pain (48%), stress (15%) and insomnia (13%), few had heard of or used CT before. Perceived mental and emotional benefits included relaxation,stress relief, relieving musculoskeletal aches and pains. Service challenges included time and funding, though staff felt CT may be cost-effective. CT may provide important support and treatment options for HIV disease, but cost effectiveness requires further evaluation.
    Full-text · Article · Feb 2014 · Complementary therapies in clinical practice
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    • "The reported effects of massage include pain relief, decreased levels of depression, improved blood flow and blood composition, reduced edema, and increased mobility of connective tissue, muscle and the nervous system [18]. It is alongside proposed that via alterations in biochemistry such as reduced cortisol levels, stress level can be reduced leading to an increase in CD4+ and CD8+ cells and in turn the general function of the immune system can be improved [42]. "
    [Show abstract] [Hide abstract] ABSTRACT: Abstract With more than 34 million of infected individuals, the prevalence of Human Immunodeficiency Virus (HIV) infection remains a perturbing pandemic that has been projected to one of the most serious significant public health concerns. Nonetheless, the introduction of highly active antiretroviral therapy (HAART) has significantly reduced Acquired Immune Deficiency Syndrome (AIDS) related morbidity and mortality. Although the quality of life of those infected has been improved, patients continue to experience physical and emotional discomforts due to the infection and/or co-infection and related treatment. The weak success of conventional biomedicine to find an effective cure for this infection has enticed patients to seek relief through the use of complementary and alternative medicine (CAM) though this means accepting certain levels of uncertainty in the hope to alleviate their suffering. Despite the widespread use of CAM, little is known about the characteristics of HIV-infected CAM users. Based on the lacuna of high-quality data reporting the use of CAM among HIV/AIDS patients, reviewing CAM use in patients on and off antiretroviral medications (ARV) is an essential baseline step to address challenges surrounding the use, safety and efficacy of CAM therapies. It therefore remains to the clinicians' obligation to inquire about CAM use when assessing, treating, and monitoring patients to ensure the effective use of CAM alongside preventing drug toxicity, treatment failure and ARV resistance. The present review has endeavoured to explore and provide updated information on the potential of common CAM therapies that have been shown to have positive health benefits in HIV/AIDS patients.
    Full-text · Article · Oct 2013
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    • "In three recent randomized control trials, Tai Chi(9) and mindfulness meditation(21) showed immune dysfunction attenuation compared to controls; a mindfulness-based stress reduction study showed reduced antiretroviral therapy (ART) symptoms and distress.(22) A Cochrane review of massage studies for HIV found that interventions that combined massage and mind-body approaches, such as stress reduction or meditation, were superior to massage alone for improved quality of life.(23) "
    [Show abstract] [Hide abstract] ABSTRACT: Self-care skills for persons living with HIV (PLWH) are needed to better cope with the common symptoms and emotional challenges of living with this chronic illness. The purpose of this study was to examine the feasibility and acceptability of Mindful Awareness in Body-oriented Therapy (MABT) for individuals receiving medical management for HIV at an outpatient program. A nonprofit outpatient day program that provided medical management to low-income individuals with HIV. A one group pre-post study design, nine participants were recruited to receive eight weekly MABT sessions of 1.25 hours each. MABT is designed to facilitate emotion regulation through teaching somatically-based self-care skills to respond to daily stressors. To assess participant characteristics and study feasibility, a battery of health questionnaires and one week of wrist actigraphy was administered pre- and postintervention. A satisfaction survey and written questionnaire was administered postintervention to assess MABT acceptability. The results demonstrated recruitment and retention feasibility. The sample had psychological and physical health symptoms that are characteristic of PLWH. MABT acceptability was high, and participants perceived that they learned new mind-body self-care skills that improved HIV symptoms and their ability to manage symptoms. The positive findings support a larger future study to examine MABT efficacy to improve coping with HIV symptoms among PLWH.
    Full-text · Article · Jun 2013 · International Journal of Therapeutic Massage & Bodywork Research Education & Practice
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