cortisol after the first and last sessions, and (b) decreased pain and pain limitations on activities over the one-month period as reported by the children, their parents, and their physicians. Fibromyalgia In a study on fibromyalgia syndrome (pain all over the body for no known etiology), patients were randomly assigned to one of three conditions: massage therapy, transcutaneous electrical stimulation (TENS, a steel roller the size of a pen that transmits a small, barely discernible current as it is rolled across the body), or transcutaneous electrical stimulation without current (SHAM TENS) for 30-minute treatment sessions two times per week for five weeks (Sunshine et al., 1997). As compared with the TENS and SHAM TENS groups, the massage therapy patients reported lower anxiety and depression, and their cortisol levels were lower immediately after the therapy sessions on the first and last days of the study. The massage therapy group also showed greater improvement on a dolorimeter measure of pain, and they reported less pain, stiffness, and fatigue and fewer nights of difficult sleeping. December 1998 • American Psychologist 1273 Lower Back Pain Lower back pain is one of the most frequent causes of absenteeism and workers' compensation claims. Massage therapy appears to provide pain relief. In one study, 24 adults with chronic lower back pain were randomly assigned to a massage therapy or a progressive muscle relaxation group (Hernandez-Reif, Field, Krasnegor, et al. 1998). Sessions were 30 minutes long and were conducted twice a week for five weeks. By the end of the study, the massage therapy group showed significant improvement in range-of-motion tests, and they reported less pain and anxiety and improved mood. They also had lower depression scores and higher serotonin and dopamine levels by the end of the treatment. Taken together, these data suggest that massage therapy is an effective primary treatment for chronic lower back pain. Another study on lower back pain involved massaging the hamstring muscle group of one randomly assigned lower extremity in a group of normal adults (Crosman, Chateauvert, & Weisberg, 1984). This treatment was considered relevant inasmuch as lower back pain is often exacerbated by tight hamstrings. The participants were given a 9 to 12-minute massage treatment to the posterior aspect of one leg. Passive range of motion of both lower extremities was measured by taking the perpendicular distance from the floor to a table surface in a straight leg raise and by conventional goniometry for hip flexion and knee extension. Measurements were taken before and after immediate massage and seven days post-massage treatment. Immediate postmassage increases in range of motion were noted in the massaged legs and not in the nonmassaged legs. Migraine Headaches At least two studies have suggested that massage therapy is also effective for migraine headaches. In one study, 26 adults with migraine headaches were assigned to a massage therapy or a standard treatment control group (a group that received medications only for migraines; Hernandez-Reif, Dieter, et al., in press). By the last day of the study the massage therapy group showed fewer distress symptoms, reported less pain, had more headache-free days, were taking fewer analgesics, and having fewer sleep disturbances, and their serotonin (5HIAA in urine) levels were higher. In a second study (Puustjarvi, Airaksinen, & Pontinen, 1990), 21 female patients suffering from chronic tension headaches received 10 sessions of upper-body massage consisting of deep tissue techniques. When found, trigger points were carefully and forcefully massaged. The range of cervical movement, surface electroneuromyography (ENMG) on the frontalis and trapezius muscles, scores on Visual Analogue Scale (VAS) and the incidence of neck pain during a two-week period before and after the treatment, together with the Beck Depression Inventory (BDI) were taken for evaluation and follow-up. The range of movement in all directions increased, and the VAS, and the number of days with neck pain decreased significantly. A significant change also occurred in ENMG on the frontalis muscle, and scores on the BDI showed significant improvement after the treatment. Potential Models for Mechanisms of Touch and Pain Relief Gate theory. Pain alleviation has most frequently been attributed to the gate theory (Melzack & Wall, 1965). This theory suggests that pain can be alleviated by pressure or cold temperature because pain fibers are shorter and less myelinated than pressure and cold temperature receptors. The pressure or cold temperature stimuli are received by the brain before the pain stimulus, the gate is closed and thus the pain stimulus is not processed. 5erotenin. Another possibility is increased serotonin levels after massage therapy for both infants (Field, Grizzle, et al., 1996) and adults (Hernandez-Reif et al., in press; Ironson et al., 1996). Serotonin may inhibit the transmission of noxious nerve signals to the brain. Sleep deficits. Another potential theory for pain alleviation from massage therapy relates to quiet or restorative sleep. During deep sleep, somatostatin is normally released (Sunshine et al., 1997). Without this substance, pain is experienced. Substance P is released when an individual is deprived of deep