ORIGINAL INVESTIGATION
Massage Therapy for Osteoarthritis of the Knee
A Randomized Controlled Trial
Adam I. Perlman, MD, MPH; Alyse Sabina, MD; Anna-Leila Williams, PA-C, MPH;
Valentine Yanchou Njike, MD; David L. Katz, MD, MPH
Background: Massage therapy is an attractive treatment option for osteoarthritis (OA), but its efficacy is uncertain. We conducted a randomized, controlled trial of
massage therapy for OA of the knee.
Methods: Sixty-eight adults with radiographically confirmed OA of the knee were assigned either to treatment
(twice-weekly sessions of standard Swedish massage in
weeks 1-4 and once-weekly sessions in weeks 5-8) or to
control (delayed intervention). Primary outcomes were
changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and functional scores and the visual analog scale of pain assessment. The sample provided 80% statistical power to detect
a 20-point difference between groups in the change from
baseline on the WOMAC and visual analog scale, with a
2-tailed ␣ of .05.
Results: The group receiving massage therapy demonstrated significant improvements in the mean (SD)
WOMAC global scores (−17.44 [23.61] mm; P⬍.001),
pain (−18.36 [23.28]; P⬍.001), stiffness (−16.63 [28.82]
mm; P⬍.001), and physical function domains (−17.27
[24.36] mm; P ⬍.001) and in the visual analog scale of
pain assessment (−19.38 [28.16] mm; P⬍.001), range of
motion in degrees (3.57 [13.61]; P=.03), and time to walk
50 ft (15 m) in seconds (−1.77 [2.73]; P⬍.01). Findings
were unchanged in multivariable models controlling for
demographic factors.
Conclusions: Massage therapy seems to be efficacious
in the treatment of OA of the knee. Further study of cost
effectiveness and duration of treatment effect is clearly
warranted.
Trial Registration: clinicaltrials.gov Identifier:
NCT00322244
Arch Intern Med. 2006;166:2533-2538
O
Author Affiliations: Institute
for Complementary and
Alternative Medicine,
University of Medicine and
Dentistry of New Jersey,
Newark (Dr Perlman); Yale
Prevention Research Center,
Yale University School of
Medicine, Derby, Conn
(Drs Sabina, Njike, and Katz
and Ms Williams).
STEOARTHRITIS (OA) AFflicts as many as 21 million Americans.1,2 It is a
dynamic process involving an imbalance in tissue homeostasis with cartilage, synovial
fluid, subchondral bone, and other joint
tissues and structures3,4 and becomes more
prevalent with advancing age.5 By 2020,
more than 50 million Americans will have
OA,6,7 which is the most frequently reported chronic condition in the elderly
population.5,8 The Centers for Disease Control and Prevention highlights OA as a
chronic condition that causes more physical limitation than lung and heart disease
and diabetes mellitus.9 The total cost of OA
was estimated at $60 billion in 2004.10
Osteoarthritis of the hip or knee is particularly disabling because it limits ambulation, but the affliction also strikes the
hands, the spine, and the feet with the same
destructive joint process.5,8 The end point
(REPRINTED) ARCH INTERN MED/ VOL 166, DEC 11/25, 2006
2533
of the OA disease process is total loss of
joint cartilage in the affected area and the
need for joint replacement.
Conventional treatments for OA include pain medication (nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors), exercises, hot and cold
therapy, corticosteroid injections, and,
eventually, surgery to repair the joint.8 Despite conventional treatment, OA is often
progressive and frequently leads to chronic
pain and disability.11 The potential toxic
effects of drugs used commonly to treat
OA have been especially newsworthy
of late.12,13
Massage therapy may diminish symptoms and improve the course of OA by increasing local circulation to the affected
joint, improving the tone of supportive
musculature, enhancing joint flexibility,
and relieving pain.14 Massage therapy has
been evaluated and found to be effective
for various painful musculoskeletal con-
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ditions.15,16 However, to our knowledge, to date, no study
has specifically evaluated the effectiveness of massage
therapy for OA. We performed a randomized, wait-list
controlled trial of 8 weeks’ duration of Swedish massage
therapy for OA of the knee.
METHODS
PARTICIPANTS
Patients were recruited from January to July of 2003 from
the Saint Barnabas Health Care System (the Carol and Morton Siegler Center for Integrative Medicine and the Arthritis
and Rheumatic Diseases Center), Livingston, NJ. The intervention was developed in conjunction with Yale Prevention
Research Center (Derby, Conn) and conducted at the Siegler
Center, located in the Saint Barnabas Ambulatory Care Center
in Livingston.
Eligible patients were men and women with radiographically established OA of the knee who met American College of
Rheumatology criteria,17 were at least 35 years of age, and had
a prerandomization score of 40 to 90 on the Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC) and
visual analog scale (VAS) pain assessment scale (0 mm indicates no pain; 100 mm, worst pain ever).18 Written confirmation of OA of the knee was provided by the patient’s physician. Patients with bilateral knee involvement had the more
severely affected knee designated as the study knee.
Exclusion criteria were the presence of rheumatoid arthritis; fibromyalgia; recurrent or active pseudogout, cancer, or other
serious medical conditions; signs or history of kidney or liver
failure; asthma requiring use of corticosteroids; use of oral corticosteroids within the past 4 weeks, intra-articular knee depocorticosteroids within the previous 3 months, or intraarticular hyaluronate within the previous 6 months; arthroscopy
of the knee within the previous year; significant injury to the
knee within the previous 6 months; or a rash or open wound
over the knee.
Participant recruitment involved informational letters to patients with OA at the Arthritis and Rheumatic Diseases Center
at Saint Barnabas Ambulatory Care Center and institutional review board–approved fliers distributed at the Saint Barnabas
Ambulatory Care Center and nearby senior living facilities and
to practicing primary care physicians in the area. Volunteers
were screened for eligibility over the telephone.
RANDOMIZATION AND SAMPLE SIZE
A research coordinator randomly assigned enrolled participants to receive either 8 weeks of massage therapy intervention (hereafter, the intervention group) or 8 weeks of usual care
on a wait-list (hereafter, the control group) followed by the intervention using a computer-generated, blocked (blocks of 6)
random allocation sequence. The control group continued with
their usual care before starting the intervention.
A sample size of 66 subjects was determined to provide 80%
statistical power to detect a 20-point difference between intervention and control groups at 8 weeks in the change on the
WOMAC and VAS scores for walking pain, with an ␣ of .05.
The standard deviation (25.7 mm) was derived from the VAS
walking pain score at 6 weeks in the acetaminophen-treated
arm as reported by Geba et al.19
Each patient provided written informed consent prior to enrollment. The institutional review boards of the Saint Barnabas Medical Center; the University of Medicine and Dentistry
of New Jersey, Newark; Griffin Hospital, Derby; and the Hu-
man Investigation Committee of Yale University, New Haven,
Conn, approved the study.
STUDY INTERVENTIONS
Two licensed massage therapists certified by the National Certification Board for Therapeutic Massage and Bodywork provided the massage therapy. The therapists used a standard Swedish full-body therapeutic massage technique20 and a standard
protocol for the study intervention, which included pétrissage
(compression or manipulation of soft tissue between the fingers and thumb), effleurage (gliding of hands over the skin or
soft tissues), and tapotement (percussion-based massage where
hands strike soft tissue in a repetitive, rhythmic fashion) techniques used at the therapists’ discretion.21,22 Massage sessions
were 1-hour long. Usual care included pain medications, exercises, or hot and cold therapy.
Initial (weeks 1-4) treatments were given with greater frequency (twice weekly) to build a loading dose of massage treatments, followed by once-weekly massage sessions for weeks 5
through 8. Participants remained supine or prone for the full
hour of treatment, turning over at roughly the halfway point.
To minimize practitioner variability of treatment, a standard
protocol incorporating specific strokes (effleurage, pétrissage,
or tapotement) was used; however, a particular sequence of
strokes was not specified. Study personnel met with the massage therapists at regular intervals to assure compliance with
the protocol. The control group continued to receive conventional medical care during the initial intervention period, then
crossed over to receive massage (weeks 9-16) after an initial
8-week delay. Study personnel prompted subjects for all scheduled appointments to minimize attrition.
OUTCOME MEASUREMENTS
All measurements were collected at baseline and after completion of intervention (at weeks 8 and 16) in both groups. Demographic data and medical history were documented by the research coordinator. Participants were instructed to keep a daily
medication usage diary.
The WOMAC is a self-administered 3-dimensional questionnaire that assesses pain, stiffness, and physical functional
disability in patients with knee and hip OA using a series of 24
questions.18 A negative change in WOMAC scores from baseline indicates improvement of symptoms and limitation whereas
a positive change indicates deterioration of symptoms and limitation. All 24 WOMAC items are rated on a numerical rating
scale (in millimeters) ranging from 0 (no symptoms/no limitation) to 100 (maximal symptoms/maximal limitation).23 The
WOMAC scores were standardized by calculating the mean of
the corresponding unweighted item scores in each dimension.24 The WOMAC global score was computed as the unweighted mean of all 24 items.
Additional outcome measures assessed at each visit included the VAS for pain assessment, which is a 100-mm-long
visual scale on which the participant draws a line to designate
their level of pain at interview; time in seconds to walk a 50-ft
(15-m) straight path; range of motion in degrees using a standard goniometric assessment as performed by a trained research assistant at the center; and adverse events (complaint, system, and severity) were recorded by the research coordinator
during her routine weekly telephone call to each participant.
STATISTICAL ANALYSIS
Descriptive statistics for each relevant variable at baseline were
determined to justify parametric methods. Continuous data are
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Table 1. Demographic and Baseline Characteristics
by Treatment Group*
68 Subjects
34 Allocated to
Intervention
Group
34 Allocated to
Control
Group
Massage Therapy
for 8 Weeks
Characteristic
Age, y
BMI
Sex, No. (%)
Male
Female
Race, No. (%)
White
Other
WOMAC score, mm
Pain
Stiffness
Functionality
Global
VAS pain score, mm
Range of motion, degree
Time to walk 50 ft (15 m), s
Usual Care
for 8 Weeks
23 Followed Up
at 8 Weeks
30 Followed Up
at 8 Weeks
Usual Care
for 8 Weeks
Massage Therapy
for 8 Weeks
15 Followed Up
at 16 Weeks
18 Followed Up
at 16 Weeks
Figure. Participant flowchart.
presented as mean (SD) in the text and tables. The paired t test
was used to examine the change in scores from baseline to follow-up examination. Changes in WOMAC and VAS scores, time
to walk 50 ft (15 m), and the clinical assessment for range of
motion between the treatment groups were measured using repeated measures analysis of variance. The 95% confidence intervals were determined for changes from baseline. The combined effect of independent variables (demographics, body mass
index, baseline WOMAC and VAS scores, and investigators’ baseline assessment for range of motion) and treatment assignment on WOMAC and VAS scores, time to walk 50 ft (15 m),
and the clinical assessment for range of motion was assessed
with multivariable models using analysis of variance. The
WOMAC findings were validated with the VAS findings and
the clinical assessment for range of motion using correlation
coefficients. Analysis followed an intention to treat design (ie,
the last value carried forward). Data were analyzed using SAS
statistical software (version 8.2; SAS Institute, Cary, NC). Significance for the 2-tailed t test was set at P⬍.05.
RESULTS
PARTICIPANTS
Of 210 candidates screened, 68 subjects participated
(34 subjects per group) (Figure). Approximately 82
(39%) of those screened were ineligible, and 60 (28%)
were unable to complete screening or were uninterested. The study groups were comparable at baseline
(Table 1); however, the mean (SD) WOMAC pain
score was higher (P = .02) in the intervention group
(52.10 [18.82] mm) vs the control group (40.69
[20.01] mm) at baseline. The stiffness, functionality,
global, VAS, and range of motion scores at baseline did
not differ between groups.
EFFICACY RESULTS
The mean (SD) WOMAC global score improved significantly from baseline value (−21.15 [22.46] mm; P⬍.001),
as did the score in each domain (pain, stiffness, and physical functional disability) (Table 2). The greatest improvement from baseline in the intervention group was
observed in pain (−23.19 [24.30] mm; P⬍.001) followed by stiffness (−21.60 [26.99] mm; P⬍.001) and
Intervention
(n = 34)
Control
(n = 34)
P
Value†
70.4 (11.3)
28.1 (7.6)
66.2 (11.3)
29.0 (6.7)
.13
.59
7 (20)
27 (79)
8 (23)
26 (76)
.77‡
29 (85)
5 (14)
29 (85)
5 (14)
⬎.99‡
40.6 (20.0)
52.3 (21.4)
49.2 (21.6)
47.6 (19.9)
62.8 (18.0)
115.6 (13.4)
15.6 (8.3)
52.10 (18.8)
60.34 (18.8)
55.1 (18.8)
54.9 (17.9)
67.2 (19.3)
109.8 (16.7)
16.7 (5.6)
.02
.11
.23
.12
.40
.11
.50
Abbreviations: BMI, body mass index (calculated as weight in kilograms
divided by height in meters squared); VAS, visual analog scale; WOMAC,
Western Ontario and McMaster Universities Osteoarthritis Index.
*Values are presented as mean (SD) except where noted.
†P values were obtained from 2-tailed t test.
‡P values obtained from 2 test.
physical function (−20.50 [22.50] mm; P⬍.001). No significant change was observed in the control group from
baseline in any of the domains. Improvements observed
in the intervention group differed significantly from
the control group (pain: −23.19 [24.30] mm vs −3.08
[17.58] mm, P⬍.001; stiffness: −21.60 [26.99] mm vs
−4.29 [24.18] mm, P = .007; physical functional disability: −20.50 [22.50] mm vs −0.02 [16.37] mm,
P= .002; and global score: −21.15 [22.46] mm vs −4.56
[15.85] mm, P⬍.001).
A similar pattern was observed in the VAS and the clinical assessment for range of motion. The change observed in VAS was highly correlated to the change in the
WOMAC global score (r = 0.84; P⬍.001). Findings persisted after controlling for demographic and baseline clinical values.
The control group in this trial received the intervention after an initial delay of 8 weeks and thus became a
second intervention group during weeks 9 to 16 (Figure).
Within-group intervention effects for the entire, pooled
study sample are thus available and are shown in Table 2.
The mean (SD) WOMAC global scores improved significantly from baseline (−17.44 [23.61] mm; P⬍.001). Significant improvement was observed in all domains (pain:
−18.36 [23.28] mm, P⬍.001; stiffness: −16.63 [28.82]
mm, P⬍.001; and physical functional disability: −17.27
[24.36] mm, P⬍.001) of the WOMAC score. The VAS
and range of motion scores also improved significantly
from baseline (−19.38 [28.16] mm, P⬍.001; and 3.57
[13.61], P= .03, respectively).
At the 16-week assessment, improvements seen in the
intervention group (massage intervention ceased at 8
weeks) largely persisted (Table 3). Comparing the improvements observed in the intervention group at week
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Table 2. Change in Outcome Measures from Baseline at 8 and 16 Weeks*
At 8-wk Follow-up†
Intervention
Group
(n = 34)
Variable
WOMAC score, mm
Pain
Stiffness
Functionality
Global
VAS pain score, mm
Range of motion, degree
Time to walk 50 ft
(15 m), s
Control
Group
(n = 34)
P
Value‡
−23.19 (24.30)
(−31.67 to −14.71)
−21.60 (26.99)
(−31.02 to −12.19)
−20.50 (22.50)
(−28.35 to −12.65)
−21.15 (22.46)
(−28.99 to −13.32)
−22.59 (25.97)
(−31.65 to −13.5)
7.15 (11.45)
(3.15 to 11.14)
−1.77 (2.73)
(−2.72 to −0.82)
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
.001
⬍.001
−3.08 (17.58)
(−9.21 to 3.06)
−4.29 (24.18)
(−12.73 to 4.14)
−5.02 (16.37)
(−10.73 to 0.69)
−4.56 (15.85)
(−10.09 to 0.97)
−1.97 (21.07
(−9.32 to 5.38)
−1.06 (14.20)
(−6.01 to 3.89)
0.24 (4.81)
(−1.44 to 1.92)
At 16-wk Follow-up
Effect
P
Value‡ Size, d
.32
0.86
.31
0.64
.08
0.74
.10
0.79
.59
0.80
.67
0.61
.77
0.50
Control
Group
(n = 34)
Pooled Analysis
Total for
Both Groups
(n = 68)
P
Value‡
−13.52 (21.49)
(−21.02 to −6.02)
−11.66 (30.13)
(−22.17 to −1.15)
−14.04 (26.02)
(−23.12 to −4.97)
−13.73 (24.48)
(−22.27 to −5.19)
−16.18 (30.24)
(−26.73 to −5.62)
−0.01 (14.78)
(−5.17 to 5.14)
0.03 (7.09)
(−2.44 to 2.50)
⬍.001
.03
.003
.002
.004
.99
.98
−18.36 (23.28)
(−23.99 to −12.72)
−16.63 (28.82)
(−23.61 to −9.65)
−17.27 (24.36)
(−23.17 to −11.37)
−17.44 (23.61)
(−23.16 to −11.73)
−19.38 (28.16)
(−26.20 to −12.57)
3.57 (13.61)
(0.27 to 6.86)
−0.87 (5.41)
(−2.18 to 0.44)
P
Value‡
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
.03
.19
Abbreviations: CI, confidence interval; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
*Pooled analysis: the intervention group at the 8-week follow-up plus the control group at the 16-week follow-up. Effect size, d =[⌬I(intervention at 8 weeks) –
⌬C control at 8 weeks]/pooled SD (ie, intervention plus control at 8 weeks). Data are given as mean (SD) (95% CI). The 95% CI is for the measured change from
baseline to follow-up assessment.
†For P⬍.05, difference between the intervention group at the 8-week follow-up and the control group at the 8-week follow-up by repeated measures analysis of
variance.
‡P values are for baseline to 8-week and 16-week measurement differences within-group paired t test.
walk 50 ft (15 m) (−2.28 [3.96] seconds vs 0.24 [4.81]
seconds; P= .02).
Table 3. Comparison Between Improvements Observed
in the Intervention and Control Groups*
Control Group
at 8-wk
Follow-up
(n = 34)
Variable
WOMAC score, mm
Pain
Stiffness
Functionality
Global
VAS pain score, mm
Range of motion,
degree
Time to walk 50 ft
(15 m), s
−3.08 (17.58)
(−9.21 to 3.06)
−4.29 (24.18)
(−12.73 to 4.14)
−5.02 (16.37)
(−10.73 to 0.69)
−4.56 (15.85)
(−10.09 to 0.97)
−1.97 (21.07)
(−9.32 to 5.38)
−1.06 (14.20)
(−6.01 to 3.89)
0.24 (4.81)
(−1.44 to 1.92)
Intervention
Group at 16-wk
Follow-up
(n = 34)
−18.52 (22.51)
(−26.37 to −10.66)
−15.51 (22.28)
(−23.29 to −7.74)
−17.05 (20.15)
(−24.08 to −10.02)
−17.23 (19.88)
(−24.16 to −10.2)
−17.15 (21.27)
(−24.57 to −9.73)
3.88 (13.61)
(−0.87 to 8.63)
−2.28 (3.96)
(−3.66 to -0.90)
SAFETY
P
Value
Subjects were instructed to report adverse events to the
massage therapist; 1 reported increased discomfort and
refused to return for the 8-week assessment.
.002
.05
COMMENT
.009
This study suggests that massage therapy using the Swedish technique is safe and effective for reducing pain and
improving function in patients with symptomatic OA of
the knee. To our knowledge, this is the first prospective, randomized trial assessing the efficacy of massage
for OA. Massage has previously shown promise for other
musculoskeletal conditions such as rheumatoid arthritis and fibromyalgia.25-27 Our results are concordant with
these prior findings.
In this study, the magnitude of the treatment effects
(ie, effect size) at the 8-week assessment in the WOMAC
scale were large, ranging from 0.64 to 0.86 (Table 2).
These effects are greater than those observed by Witt et al28
in a large acupuncture trial of similar design.
Using intention-to-treat analysis and carrying forward baseline values likely biased our results toward the
null. The treatment effects observed were stronger when
limited to only those subjects returning for follow-up.
Thus, our findings are a conservative estimate of the magnitude of treatment effect. Losses to follow-up, shown
in the Figure, are reflective of the real-world experience
with an elderly population with impaired mobility.
.005
.004
.15
.02
Abbreviations: CI, confidence interval; VAS, visual analog scale; WOMAC,
Western Ontario and McMaster Universities Osteoarthritis Index.
*Data are given as mean (SD) (95% CI). The 95% CI is for the measured
change from baseline to follow-up assessment.
16 (ie, 8 weeks after the intervention was completed) with
the control group at week 8 (ie, at the end of their nonintervention period) revealed significant, residual mean
(SD) differences in pain (−18.52 [22.51] mm vs −3.08
[17.58] mm; P=.002), function (−17.05 [20.15] vs −5.02
[16.37]; P=.009), WOMAC global score (−17.23 [19.88]
mm vs −4.56 [15.85] mm; P⬍.005), VAS score (−17.15
[21.27] mm vs −1.97 [21.07] mm; P= .004), and time to
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We used a wait-list control design because no validated method of performing “placebo massage” has been
developed. This did result in increased contact with study
personnel for the intervention group during the 8-week
intervention. Although Hawthorne effect29,30 may have
been a factor in our results, both intragroup and intergroup differences were significant at 8 weeks, and the improvements in the intervention group largely persisted
at the 16-week follow-up, which was 8 weeks after the
subjects finished the weekly massage sessions.
We used Swedish massage because it is one of the more
common and readily accessible or practiced techniques
in the United States.22 There was limited precedent for
selecting frequency, duration, or even type of massage.
There may prove to be more—and less—effective approaches, and this will need to be elucidated in subsequent studies.
The potential importance of massage as an adjunct to
or even an alternative to pharmacotherapy is selfevident. Current pharmacological treatments for OA are
associated with high rates of adverse effects, such as cardiovascular, gastrointestinal, renal, and hepatotic toxic
effects.1,13,31-34 Many patients are already adding or trying massage as a therapy for OA.35-38
There are also nonconventional and nutriceutical treatments for OA. Trials regarding the efficacy of glucosamine with or without chondroitin are inconclusive.
However, a recent randomized controlled clinical trial (the
Glucosamine/chondroitin Arthritis Intervention Trial39) suggested that the combination is effective for patients with
moderate to severe OA pain. Other nutriceutical treatments, including devil’s claw and ginger,35 have yet to be
proven effective. Recent research has suggested that acupuncture may also be an effective option for patients with
OA.40 Establishing massage as a therapy for OA would provide an additional option to the current approaches.
Study limitations include a single intervention and homogeneous study sample. Study participants were recruited in northern New Jersey, and most of the subjects in the intervention and control groups were white
women; demographic homogeneity may limit generalizability. However, in individuals older than 50 years, knee
and hand OA is more prevalent in women than men.5
Black and white individuals have similar rates of OA, although higher body weights may contribute to a slightly
higher prevalence in black persons.5
The study duration was only 16 weeks; OA is a chronic
condition, and therefore longer studies will be needed.
Losses to follow-up were noteworthy. However, an intention-to-treat analysis was used, and therefore our findings may be conservative estimates of treatment effect.
Because participants did not keep accurate medication diaries, we cannot reliably know if change in medications in any way affected our results. It seems unlikely that the massage intervention would have caused
participants to increase their medication in such a way
as to lead to significant improvement in pain and function compared with the control group. Bias toward a null
effect is more probable.
In conclusion, this pilot study suggests that massage
therapy is efficacious in the treatment of OA of the knee,
with beneficial effects persisting for weeks following treat-
ment cessation. Massage therapy seems to be well tolerated by people with painful OA of the knee. Massage also
seems to decrease pain and improve function in participants who were allowed to maintain their usual treatment. Given the limitations and potential adverse effects of pharmacologic and nonpharmacologic treatments
for OA, massage therapy seems to be a viable option as
an adjunct to more conventional treatment modalities.
Further study of massage to determine optimal treatment protocols, absolute efficacy, cost-effectiveness, and
generalization to other patient groups is clearly warranted.
Accepted for Publication: September 1, 2006.
Correspondence: Adam I. Perlman, MD, MPH, University of Medicine and Dentistry, School of Health Related
Profession, Institute for Complementary and Alternative Medicine, 65 Bergen St, Stanley S. Bergen Bldg, No.
101, Newark, NJ 07107-1709 (a.perlman@umdnj.edu).
Author Contributions: Study concept and design: Perlman,
Sabina, Williams, and Katz. Acquisition of data: Perlman.
Analysis and interpretation of data: Perlman and Njike.
Drafting of the manuscript: Perlman, Sabina, and Williams.
Critical revision of the manuscript for important intellectual content: Perlman, Sabina, Williams, Njike, and Katz.
Statistical analysis: Njike. Obtained funding: Perlman and
Williams. Administrative, technical, and material support: Perlman, Sabina, and Williams. Study supervision:
Perlman and Katz.
Financial Disclosure: None reported.
Funding/Support: This study was supported by the Centers for Disease Control and Prevention (grant SIP-1400) and Prevention Research Center core grant U48CCU115802.
Acknowledgment: We thank Michael Yablonski, NCTMB,
massage therapist, Linda Winz, NCTMB, massage therapist, and Marie K. Saimbert, MLIS, Elena Mojica, MPH,
and David Hom, MS, for their contributions.
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