Review The effect of massage on patients with chronic fatigue syndrome: A systematic review and meta-analysis 2024 Li et al

[Hutan]

The search terms include “chronic fatigue syndrome” or “myalgia encephalomyelitis” or “fatigue syndrome” or “fatigue” and “tuina” or “massage” or “acupoint massage”; “massotherapy.”

They did not search on ME/CFS

They included 32 studies. All were undertaken in China, so I think that we can assume that the treatment studies is in fact tuina, not general massage. So, it seems that this paper is for a population that is not the same as ME/CFS and it is recommending a treatment that is not the same as the sort of massage most people would typically access in western countries.

Blinding by researchers/subjects: Only one study mentioned the use of single blinding for subjects, while the remaining studies did not mention the use of blinding.
Selective reporting of research results: No research reports on follow-up status.
Integrity of outcome data: Only three studies reported dropout status, and in the remaining included studies, there were no established criteria for termination, exclusion, or dropout, nor were there any reports of dropout.

The studies are sounding as if they have a high risk of bias, with unblinded treatments, subjective outcomes, no follow-up measures, little reporting on attrition. However this review does not rate many studies as having a high risk of bias.

 

[Hutan]

Results of the Chalder Fatigue Scale:

Six studies reported FS-14 scores involving 360 subjects.[21,23,41,47–49] The analysis results are shown in Figure 5; The heterogeneity included in the study was high (P < .00001, I2 = 75%), and statistical data was merged using a random effects model; The FS-14 fatigue scale score of massage therapy for chronic fatigue syndrome was significantly lower than other therapies (MD = −1.59, 95% CI = −1.84, −1.34), and the difference was statistically significant (P < .00001).

Only six studies. The mean difference was only a reduction of 1.59. That's unlikely to be a clinically significant difference, and is certainly in the realms of placebo/experimental bias.

It is clear that there was an inadequate accounting of treatment harm. And yet, the fact that only one study reported on harms did not stop the investigators reporting

According to the results presented in this study, it has been confirmed that tuina therapy is effective in treating this disease. And massage therapy can provide patients with a comfortable and painless treatment plan.

 

[Hutan]

Tuina can regulate the psychological and physical symptoms of patients through manual operation, making up for the lack of high acceptance and execution requirements of cognitive behavioral therapy on subjects.

Reading between the lines there, that study I mentioned up thread (reference [10]) that found that the percentage of people with CFS having the right psychological characteristics to do CBT was low, must have had problems with people not wanting to do it.

 

[Hutan]

While the 14-item scale was used in several studies in the 1990s, the 11-item version is the most used version, today.

1. Do you have problems with tiredness?
2. Do you need to rest more?
3. Do you feel sleepy or drowsy?
4. Do you have problems starting things?
5. Do you lack energy?
6. Do you have less strength in your muscles?
7. Do you feel weak?
8. Do you have difficulties concentrating?
9. Do you make slips of the tongue when speaking?
10. Do you find it more difficult to find the right word?
11. How is your memory?

The deteled items from the 14-item scale are:

• Do you start things without difficulty but get weak as you go on?
• Do you think as clearly as usual?
• Are you still interested in the things you used to do?

In the bimodal scoring system, respondents answer each question with a 1 or a 0 to indicate the questions apply to them or not.
In the Likert scoring system, respondents can give a score of 0 to 3 to indicate how each statement applies to them, from “less than usual” to “much more than usual”.[15]

If we take the reported data from one study that is in the mid range, Feng Wei 2022
Experimental treatment:.....Mean 4.9........SD 1.29
Control treatment:............Mean 5.95........SD 1.5
Mean difference -1.05

I don't really know what these numbers are. I can't find the actual study online. I think these must be the post-treatment scores, for tuina and for a control. I don't know what the scoring system used was, but, even it was the bimodal system, a difference of 1 is nothing much.

I can't really see how you can combine studies that are comparing all sorts of different things. But it seems that it doesn't matter what you compare tuina with, it always seems to come out just a bit better than the other thing.

Feng Wei 2022 : massage vs traditional Chinese medicine : -1.05
Liang Feng 2014: massage vs acupuncture : -2.52
Sun Dong Wei 2022: massage + acupuncture vs acupuncture : -2.00
Wu Xingquan 2011: massage + traditional Chinese medicine : -1.09
Yao Wei 2012: massage vs psychotherapy : -0.77
Qi Fengjun: 2020: massage vs acupuncture : -2.00

I think that's more effort than this deserves. I'll stop now.

 

[Deanne NZ]

Thanks for going to such extraordinary effort to determine if there was any merit in the doctor’s recommendation. It does not bode well for their credibility. They lost me at the comment that they have either never or rarely see cfs patients with weight loss. A self-proclaimed expert no doubt who does not keep up with current issues & research.

 

[Hutan]

One last comment - in the included 32 studies, tuina was compared with an extraordinary range of treatments: moxibustion, hyperbaric oxygen therapy, Nursing treatment, psychotherapy, cupping jar, acupuncture, traditional Chinese medicine of various sorts, western medicine of various sorts...

And tuina was better than them all.

And yet, that acupuncture review that I looked at yesterday compared acupuncture and moxibustion with all sorts of treatments, including tuina and traditional Chinese medicine. And it concluded that acupuncture and moxibustion (sometimes with other things added) was better than other treatments.

I guess that's the beauty of subjective outcomes with unblinded treatments and all the other subjectivity of the review process - anything can be better than everything else, all at once.

 

[Hutan]

In case anyone else ever wants to try to head off a recommendation for massage as an ME/CFS treatment, there might be some lines in the following. The tone is fairly chatty rather than scientific, as that is what is appropriate to the channel I'm working in. Feel free to argue with what I have written.

There is no good evidence that massage is a useful treatment for ME/CFS. Despite the lack of evidence, it is sometimes recommended as a treatment, possibly as a result of a general feeling that ‘those people need to relax more’, or ‘it’s a nice thing that won’t cause any harm’. Anecdotally, many people with ME/CFS find that deep massages cause post-exertional malaise (e.g. ending up in bed for several days in pain and feeling ill); I have experienced this repeatedly myself. I know it sounds unbelievable (I had trouble believing it which is why I experienced it repeatedly), but, perhaps there is a difficulty with recovering from damage to muscle cells.

While a warning against deep massage may be premature in clinical guidance, there is certainly no basis for recommending massage as an ME/CFS treatment. Massage might be useful for some specific symptoms that people with ME/CFS may develop. For example, massage might be useful to help maintain blood circulation and range of movement in people who are bedbound. Presumably though, this can be covered in health pathways for the management of bedbound patients in general.

The paper the doctor cites as evidence is ‘The effect of massage on patients with chronic fatigue syndrome: A systematic review and meta-analysis, 2024, Li et al’.

This is actually a systematic review of tuina, traditional Chinese massage, and all of the studies are Chinese. There are many problems with this review. Perhaps the most important one is that the conception of chronic fatigue syndrome is consistent with the estimate of the prevalence of CFS in China quoted in the paper. The prevalence is reported as 12.5%, substantially more than common estimates of ME/CFS prevalence of 0.4%. The study participants are therefore probably essentially anyone with chronic fatigue who has not (yet) been diagnosed with another medical condition. The combination of an inaccurate idea of what ME/CFS is, together with the fact that the massage treatment is not the same as what most New Zealanders would be able to access, means that the review is not relevant as evidence for massage in ME/CFS.

Much like the acupuncture review, that is only the start of the problems. The studies included are very poor quality. The outcomes are subjective, the treatments are unblinded. The reported benefits are small, well within the range that would be expected from a placebo and poor experimental design. Harms were only reported in one study – harm included local swelling, bruising and nausea; attrition was not reported. There were no followup measurements. The investigators rejected studies where tuina was the control treatment (e.g. versus acupuncture), while accepting studies where tuina was the treatment (e.g. with acupuncture as the control). This biased the selection, resulting in only studies where the researchers expected massage to be the superior treatment being included.

There are unevidenced and wildly inaccurate claims in the review, as shown in this excerpt:

“However, from the perspective of traditional Chinese medicine, we believe that there are three causes of CFS: Traditional Chinese medicine believes that emotions have a significant impact on the liver, and patients have poor emotions due to various reasons, leading to liver injury, resulting in common manifestations of CFS such as mental depression, chest and rib pain, breathing difficulties, breast and abdominal distension, abnormal bowel movements, and menstrual irregularities; The patient’s careless diet leads to spleen and stomach injury, weakened digestive function, insufficient nutrition supply, and clinical manifestations such as indigestion, bloating, constipation, and physical fatigue; and Traditional Chinese medicine believes that attention, sleep, and other aspects of the human body belong to the management of the heart. Patients often think excessively and damage the heart, resulting in symptoms such as insomnia, excessive dreaming, forgetfulness, lack of concentration, and overreaction to external stimuli.”

There is no evidence that ME/CFS is caused by ‘poor emotions’, ‘careless diet’ or ‘thinking excessively’.

 

[Wyva]

Maybe about a year ago someone in my group, a recovered covid long hauler asked me about this. She was very interested in Chinese medicine and recently started learning massage as a hobbi (maybe she even said she had found massage helpful, I don't remember now). She asked me if she could offer her massage service to pwME in my group, to practice on them, with the intent to also help. I thought maybe some people might find it pleasant but I still declined. She had said many things before that really rubbed me the wrong way, I also had no way to tell if she was actually trying to build her future clientele and the most important of all: I really didn't think experimenting with or practicing unevidenced treatments on often very desperate pwME was a good idea, so I said no. Reading some of these comments tells me it wasn't a bad call.

 

[shak8]

A major factor behind the rise in traditional Chinese Medicine published research studies is:

that the current Chinese government has been actively promoting TCM (see any internet search) to boost their goal of political nationalism, to highlight Chinese civilization for their political agenda.

I think this is an important underlying fact to consider, given the rising number of TCM studies with sophisticated clinical statistical methods.

TCM falls into the "hands-on" approach which is loaded with placebo response, due to such things as the warmth or attractiveness of the practitioner, the belief in the efficacy of a particular TCM therapy or the belief one has in an individual practitioner's skill.

I lived through the 1960s during the hippie, back-to-nature, the embrace of Eastern religions and culture, the rise in the US of alternative, integrative medicine.

I studied the local Native American tribe and noted their cure for illness (the 'sucking doctor' who uses her mouth directly on body parts to apply suction as a cure for medical illness).

The likelihood of any of these TCM practices (other than herbs which may or may not have been fully studied) to have a meaningful clinical effect on a serious medical malady is close to nil.

 

[rvallee]

One last comment - in the included 32 studies, tuina was compared with an extraordinary range of treatments: moxibustion, hyperbaric oxygen therapy, Nursing treatment, psychotherapy, cupping jar, acupuncture, traditional Chinese medicine of various sorts, western medicine of various sorts...

And tuina was better than them all.

And yet, that acupuncture review that I looked at yesterday compared acupuncture and moxibustion with all sorts of treatments, including tuina and traditional Chinese medicine. And it concluded that acupuncture and moxibustion (sometimes with other things added) was better than other treatments.

I guess that's the beauty of subjective outcomes with unblinded treatments and all the other subjectivity of the review process - anything can be better than everything else, all at once.

Hey, maybe they discovered the first true perpetual motion mechanism. Don't dismiss this out of hand!

A > B > C but C > A which means that mathematically you get a mutually interacting quantum field of motion so that the universe must respect the expected symbols and the expectations behind it and produce motion from it.

Damn, pseudoscience is really easy stuff. You just basically say whatever and pretend like it's profound. I guess the secret is that you need an audience that nods in agreement and will throw money at you to keep going. Yeah that's definitely the secret sauce here, and why evidence-based medicine is so damn popular: you can say whatever and it literally doesn't matter as long as your audience wants it to be true.

 

[rvallee]

The likelihood of any of these TCM practices (other than herbs which may or may not have been fully studied) to have a meaningful clinical effect on a serious medical malady is close to nil.