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specific population such as pediatric or infant massage. After factoring in these exclusions and eliminating repeat results, there were a total of fifteen articles selected. Of the articles selected for the literature review, the overall rating of evidence was high. All but five were randomized controlled studies (RCTs), which rank as level I evidence according to the John Hopkins Evidence Based Practice Levels of Evidence (Newhouse et al., 2005). The evidence also included a single blind experimental study (Akca et al., 2015), and a mixed method experimental study (Coakley et al., 2016), which also rank as level I evidence. Remaining were a pilot prospective non-randomized intervention study (Garner et al., 2008), and a quasi-experimental study with repeated measures (Rexilius et al., 2002), which rank at level II. Finally, the results included one observational study (McMillan et al., 2018), which classifies at the level III rating of evidence (Newhouse et al., 2005). Evidence Based Practice There was strong evidence within this review that massage therapy can be a valuable tool in the treatment of depression. Positive findings regarding the use of massage therapy for treatment of depression were found in the RCTs by Poland et al. (2013), and Lee and Yeun MASSAGE THERAPY 13 (2007), with p < 0.005 and p = 0.001 in each. A RCT by Moghaddasifar et al. (2018) investigated the use of multisensory stimulation on depression and anxiety; treatment included the tactile intervention of ten-minute hand massages over the period of four weeks. Results showed a statistically significant decrease in depression scores by 4.4 (p >0.001). Another RCT examining the effects of sleep and touch therapy on symptoms of fibromyalgia and depression showed that massage on fibromyalgia pressure points along with the use of music and aromatherapy, reduced Beck Depression Index scores significantly with p = 0.01 (Demirbağ & Erci, 2012). The study by Field et al. (2004), demonstrated the effectiveness of massage therapy for symptoms of depression and anxiety (p < 0.001). They also showed changes in levels of key neurotransmitters involved in the pathogenesis of depression including higher levels of dopamine and serotonin and decreased levels of cortisol and norepinephrine following massage. Finally, a 2020 RCT by Bahrami et al., which compared the use of reflexology massage to aromatherapy for treatment of depression and anxiety in hospitalized older women, showed significant positive results with reflexology. Although there was a significant reduction in symptoms of depression and anxiety in both groups, reflexology (p = 0.001) was shown to have a better effect than aromatherapy as measured by the hospital anxiety and depression scale. The overall findings for the use of massage therapy for the treatment of anxiety were very promising. The most commonly used measurement tool amongst the reviewed studies was the State Trait Anxiety Inventory (STAI), or an adaption thereof, with similar findings noted amongst the following studies: Utilizing chair massage, Diego et al., showed anxiety on the STAI with p < 0.001 after the first session and p < 0.05 after the last session. Black et al. (2010), had similar results with chair massage with improvements on state and trait anxiety with p < 0.001. Coakley et al. (2016) also noted improvements to the STAI with the use of therapeutic MASSAGE THERAPY 14 touch with p = 0.000. The RCT by McMillan et al. (2018), demonstrated the efficacy of Swedish massage for anxiety through the STAI with p = 0.002. Through the use of therapeutic massage garner et al. (2008) also measured improvements in anxiety through implementation of the STAI. Significant improvement was noted post intervention with p < 0.001. Also measured in this study were heart rate and cortisol levels, with positive findings (p < 0.05) for both.

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