A systematic review of manual therapy modalities and anxiety

Inclusion and exclusion criteria

Studies were included if they met the following criteria: (1) written in English; (2) peer-reviewed; (3) contained documented anxiety conditions (e.g., anxiety conditions as a primary focus and objective of the conducted study); (4) utilized a validated anxiety measure prior to and after intervention; and (5) included a manual therapy modality delivered by a qualified professional. We excluded studies that contained invalid author conclusions or lack of an intervention. Meta-analyses and systematic reviews were not included, because the inclusive review articles were instead obtained through their original publishing.

Study selection

Both authors screened all titles and abstracts against the selection criteria and concurred on a vast majority of them. The researchers then reviewed all full-text articles to ensure that the inclusion criteria were met (Figure 1). When reviewer article selection discrepancies arose, all authors reread full-text studies and discussed the inclusion and exclusion criteria for each article to achieve consensus. Citations were generated through Citation Machine or obtained through original article publication.

Data collection

Screening was performed in duplicate interdependently. Utilizing the LOE criterion from Ebell et al. [10] and an individualized article elements template, data were extracted for each study by both reviewers (Table 1). Article elements included the type of manual therapy modality, the training of those performing the modality, anxiety conditions, the patient population, the measures utilized, outcomes, and the accuracy of the author’s conclusion. Results were analyzed according to the type of therapy. Interventions included massage therapy, OMT, foot reflexology, therapeutic touch, manual therapy, and acupressure. All reported-effect measures for outcomes were drawn from the study data and were not independently verified given the number of included studies and that all included studies were peer-reviewed. The LOE criterion were applied independently by both authors.

Quality assessment

The quality of evidence for each modality was assessed utilizing the Strength of Recommendation Taxonomy (SORT), an evidence-based medicine system categorizing recommendations into three levels based on evidence quality and risk-benefit balance [10]. These levels, detailed in Table 1, range from “A” for a Strong Recommendation to “C” for a Weak Recommendation. Ratings were independently made by both researchers on this A–C scale. When reviewer rating discrepancies arose, all authors reviewed A–C scale qualifiers together to achieve consensus.

Massage therapy

In our assessment of 18 massage therapy studies, 15 demonstrated a statistically significant positive impact on state and/or trait anxiety reduction, as documented in Table 3 [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. An LOE one randomized clinical controlled trial targeted individuals with fibromyalgia, assessing the potential of massage therapy to alleviate anxiety symptoms. Utilizing the State-Trait Anxiety Inventory (STAI), 64 patients reported their feelings at various intervals, revealing a significant improvement in trait anxiety (p<0.041) in the experimental group immediately after the 20-week intervention. This improvement persisted at the one-month postintervention assessment (p<0.043) [12]. Another study involving 72 hospitalized children and adolescents utilized STAI for children, Profile of Mood States (POMS), and salivary cortisol levels, showed reduced anxiety in subjects receiving massage on days 1 and 5 [17]. Additionally, caregivers of patients undergoing a stem cell transplant experienced a statistically significant decline in anxiety scores (p=0.004) only in the massage therapy group, as measured by the Beck Anxiety Inventory (BAI). The therapeutic touch group exhibited decreased anxiety scores, although statistical significance was not achieved [25].

Osteopathic manipulative treatment (OMT)

A total of six studies discussing anxiety level reduction were also conducted utilizing OMT [6, 7, 29], [30], [31], [32]. A study from the Clinic for Mood and Anxiety Disorders in Ontario concluded that adult participants with a primary diagnosis of moderate-severe generalized anxiety disorder (GAD) experienced significant reductions in total Hamilton Anxiety Rating Scale (HAM-A) scores after OMT (p<0.001). Response (defined as a 50 % or greater reduction of anxiety symptoms) and remission (HAM-A score≤7) rates were found to be 62 and 26.0 %, respectively [30]. Furthermore, researchers conducted a high-quality randomized controlled trial of 34 asymptomatic female patients, discovering that global self-perception and anxiety were significant main effects of the OMT intervention (p<0.0001) [29]. In contrast, a study consisting of 30 patients with irritable bowel syndrome (IBS) were assigned to either an OMT group or a sham group that received a gentle massage over the spine and abdomen. Utilizing the Hospital Anxiety and Depression (HAD) scale. In patients treated with osteopathy, the HAD scores remained unchanged at day 7 (15.7 ± 7.8, p=0.7 vs. day 0) but decreased significantly at day 28 (6.7 ± 4.7, p<0.01 vs. day 0 and p<0.01 vs. day 7). In patients receiving the sham procedure, the HAD score was not significantly changed at day 7 (16.4 ± 7.2, p=0.5 vs. day 0) and decreased at day 28 (6.2 ± 5.5, p<0.001 vs. day 0 and p<0.001 vs. day 7). Therefore, there was no significant difference at any time between the OMT group vs. the sham procedure [32].

Foot reflexology

This systematic review incorporates five studies investigating the efficacy of foot reflexology in reducing anxiety symptoms [33], [34], [35], [36], [37]. Three studies specifically address foot reflexology’s application in anxiety reduction for burn patients. In a randomized controlled trial with 36 burn center patients, foot reflexology yielded no significant difference in STAI scores between the experimental groups (p>0.05). However, a notable distinction emerged on the fourth day, with lower STAI scores in the experimental group (p<0.05), further pronounced (p<0.0001). Repeated measurements validated a significant decrease in STAI scores on the fourth day compared to the first day in the experimental groups (p<0.05), contrasting with the control group’s higher scores on the fourth day (p<0.05) [36]. Another study involving 52 burn intensive care unit patients assessed the impact of foot reflexology massage on burn pain anxiety. Before intervention, both of the groups exhibited high anxiety levels. Significant differences were observed in the pain anxiety scores between the groups on the third, fourth, and fifth days and 15 min postintervention. The Burn-Specific Pain Anxiety Scale (BSPAS) indicated a decrease in pain anxiety levels in the intervention group from the third day to the fifth day (p<0.001), whereas the control group experienced a slight increase in pain anxiety levels postdressing change (p<0.001) [35]. In a randomized controlled trial with 66 burn-injury patients, the intervention group – receiving foot reflexology alongside standard care – demonstrated a significant decrease in anxiety scores from the fourth day to the sixth day (p<0.001). Conversely, the control group maintained higher anxiety scores, with significant differences observed on the fourth day (p<0.01), fifth day (p<0.001), and sixth day (p<0.001) days, highlighting the consistent anxiety reduction achieved by foot reflexology compared to standard care [34].

Acupressure

A single study was identified utilizing acupressure for anxiety symptom reduction [38]. In this study, 120 Iranian army soldiers were enrolled in a randomized double-blind design. Participants were assigned to P6 or LI4 acupressure points or a control group. Preintervention showed no significant anxiety-level differences. Postintervention, the P6 group exhibited a notable decrease in mean anxiety scores from 53.35 ± 9.7 to 49.02 ± 9.3 (p=0.005), indicating significant improvement. The LI4 group also demonstrated substantial reductions from 53.37 ± 8.39 to 45.47 ± 8.16 (p<0.001). Conversely, the control group showed no significant pre-post difference (p=0.16). Postintervention, the analysis revealed a significant difference in anxiety levels among the three groups (p=0.04) [38].

Manual therapy

Two studies investigated manual therapy for anxiety [39, 40]. In a study with 44 patients experiencing subacute and chronic nonspecific neck pain, interventions like Maitland and Mulligan techniques were compared. Both groups exhibited high adherence to treatment sessions, with no significant difference in the number of sessions. Medication usage decreased postintervention. The STAI scores significantly reduced in both groups, with the Maitland group showing STAI forms at p=0.001 and the Mulligan group showing STAI forms at p=0.002 and p=0.043, respectively [39, 40].

Healing touch

In the course of the review, two articles were identified addressing the subject of healing touch [24, 25]. Neither of these articles demonstrated statistically significant reductions in anxiety. Specifically, a study by Post-White et al. [26] examined a cohort of 164 patients diagnosed with diverse forms of cancer. Despite the findings of additional favorable effects linked to healing touch, the anxiety symptoms exhibited a nonsignificant p value of 0.36.

Therapeutic touch

A single study addressed therapeutic touch and anxiety reduction, involving 41 healthy females [41]. Anxiety symptoms were measured utilizing STAI and POMS. The treatment group demonstrated significantly greater reductions in anxiety symptoms (p<0.01), particularly in self-reported tension (p<0.05), indicating the effectiveness of therapeutic touch as a relaxation technique. Despite treatment group participants rating their health more negatively, they showed greater anxiety reductions than control group participants after therapeutic touch sessions [41].

Gentle touch

One study was identified covering the topic of gentle touch and anxiety symptom reduction [42]. In this study conducted at The Center for Complementary Care in the United Kingdom, 147 individuals were enrolled in a trial to study psychological well-being after therapeutic touch treatments. Of the 147 study participants, 32 presented to the trial with a diagnosis of anxiety. Changes in anxiety proved to be highly significant after treatment (p<0.0004). Of those taking medication at the time of entry (n=73), 16 % ceased taking their medication, 37 % reduced their medication, 40 % maintained their medication, and 7 % increased their usage of medication [42].

Additional observations

Six of the trials evaluated the effects of variable manual therapy modalities on burn patients, with 4/6 (67 %) reporting improvements in patients’ state and/or trait anxiety. Only 5 of the 34 studies included patients with diagnoses of GAD, depression, adjustment disorder, depression, dysthymic disorder, or posttraumatic stress disorder (PTSD), with 3/6 (50 %) articles demonstrating a positive reduction of anxiety symptoms with manual therapy.

Utilizing the Strength of Recommendation (SOR) algorithm [3], all therapeutic modalities included in this systematic review were assigned a “B” rating.

Massage therapy

Our literature review indicates a consistent reduction in anxiety levels postmassage therapy administered by trained professionals. Recognized as a safe, cost-effective, and easily learned modality, massage therapy can be employed by various individuals, including medical professionals, family members, and volunteers, to alleviate anxiety. However, the variability in the training backgrounds of professionals, ranging from volunteers to therapists, poses a challenge in standardizing interventions. The limited reporting of power values in 11 out of 21 studies raises concerns about unreliable findings due to inadequate sample sizes [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. Additionally, the focus on GAD in only 4 out of 21 studies limits the applicability of the results to this specific population, urging caution in generalizing findings from the reviewed massage therapy studies, particularly for patients with GAD [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28].

Osteopathic manipulative treatment (OMT)

The review of the literature on the impact of OMT aligns with existing studies, emphasizing its potential benefits in addressing state and/or trait anxiety, especially in complex, comorbid presentations. OMT’s multifaceted approach targets systemic concerns, offering short-term anxiety reduction after a single session. However, only five out of six articles documented power values, limiting the reliability of the findings [6, 7, 29], [30], [31], [32]. The diverse training backgrounds, including nonphysician osteopaths and a psychiatry resident, raise questions about standardization. Moreover, just one out of six articles focused on patients with a specific anxiety disorder diagnosis, with one study examining the impact on asymptomatic healthy adult females [6, 7, 29], [30], [31], [32]. These variations highlight the contextual importance and specific conditions influencing OMT effectiveness, underscoring the need for further research, especially in primary anxiety disorder patients.

Foot reflexology

The results from the reviewed studies collectively suggest that foot reflexology reveals promising efficacy in reducing anxiety symptoms among burn patients. These results collectively emphasize the potential of foot reflexology as a valuable complementary intervention for managing state and/or trait anxiety in burn patients. The observed reductions in anxiety scores across different studies and settings indicate a consistent trend, emphasizing the need for further integration of foot reflexology in holistic patient care modalities for individuals undergoing burn treatment. Of note, three out of five studies did not calculate or include a power value to indicate significance of their total sample population [33], [34], [35], [36], [37]. Training of those performing foot reflexology includes nurses and researchers trained in this practice and/or with certification and practicing reflexologists. This systematic review did not identify any studies comparing the effects of foot reflexology to a specific anxiety disorder. Therefore, this area of research must be developed to provide evidence for efficacy in variable patient populations.

Acupressure

The single study of acupressure and anxiety suggests that both P6 and LI4 acupressure points may effectively reduce anxiety [38]. The study’s design adds weight to these results, highlighting potential applications in mental health interventions beyond the military context. Only one article discussed acupressure for patients with state and/or trait anxiety. This study calculated a significant power value. The therapist delivering the treatment was trained in acupressure. The study population included Iranian soldiers without a documented anxiety disorder. A significant limitation of this study is the potential challenge in generalizing its findings to other patient populations [38].

Manual therapy

The single research article, utilizing Maitland and Mulligan techniques, contributes to the advancing acceptance of manual therapy as an effective intervention for anxiety symptom reduction [39, 40]. The observed reductions in medication usage and anxiety levels suggest that these interventions may offer complements to conventional treatments for individuals with neck pain, warranting further studies to bolster the claims made in this study. Neither of the two articles calculated a power value, thus limiting the LOE supporting the article claims. All practitioners delivering the treatment were trained massage therapists. One article discussed the changes in state and/or trait anxiety in patients with PTSD. Thus, no included articles focused on patients with a clinically diagnosed anxiety disorder [39, 40].

Healing touch

The “B” classification for healing touch implies that it might not be highly effective. Examining the two articles focused on healing touch for anxiety reduction reveals a consistent lack of statistically significant differences in symptom reduction [24, 25]. This underscores the need for more research to better understand the effectiveness of healing touch for managing anxiety, because the current evidence does not strongly support its impact.

Therapeutic touch

Examining therapeutic touch for anxiety reduction sheds light on its potential efficacy. The findings suggest that therapeutic touch might enhance traditional anxiety treatments when utilized in a multimodal therapy [41]. While these findings hint at integrating therapeutic touch into mental healthcare, future research should prioritize standardized methods and long-term assessments for generalizable results, ensuring an evidence-based approach in clinical settings.

Gentle touch

One article focused on gentle touch for reducing anxiety symptoms [42]. Although this study revealed statistically significant differences before and after treatment, future research credibility would benefit from employing a more reliable measure for anxiety symptoms, rather than relying solely on self-completed questionnaires, to include the Visual Analog Scale (VAS).

Limitations

This paper has limitations that warrant consideration. It acknowledges variations in study design, anxiety measures, patient populations, and practitioner training across modalities, suggesting a need for a more in-depth exploration of these differences to enhance the paper’s depth. Additionally, the reliance on convenience samples in many studies without specific discussions on power analysis for sample size calculation limits the strength of their conclusions. The absence of long-term follow-up in several studies and the predominant short-term focus may hinder this study’s generalizability. The authors acknowledge the lack of standardization of the included studies that limit a definitive conclusion of efficacy in anxiety disorders. To address these limitations, future research should delve into the impact of variations in study parameters, prioritize power analyses, standardized anxiety measures, and incorporate longitudinal studies with extended follow-up periods for a more comprehensive understanding of the lasting effects of manual therapy modalities on anxiety. Strengthening these aspects would enhance the study’s credibility and its contribution to informing clinical practice and future research directions.