the reduced range of motion ( rom ) of the shoulder is a common and disabling problem for 
 patients with shoulder pain1 . shoulder 
 pain and reduced rom do not improve over time and are persistent or repeated in many 
 cases2 . massage therapy is one of the 
 complementary and alternative intervention for improving the functional status for patients 
 who had impaired shoulder function in physical therapy clinics3 . it relieves the muscle hardness by applying mechanical pressure on 
 the affected area using the hands , and improves the rom of the joints4 . in addition , it improves the excitability of the nerves in 
 the muscle fiber and inhibits muscle pain5 . massage therapy is also known to improve edema by promoting blood 
 circulation within the muscle , and helps remove fatigue substances6 . massage therapy is frequently used as a method of improving the shoulder rom , but there 
 have not been many studies that comprehensively investigated its effect on the shoulder rom . only van den dolder et al.7 conducted a 
 meta - analysis of the effect of soft - tissue massage and exercise on the shoulder rom . the aim 
 of this study , therefore , was to conduct a systematic review and meta - analysis assessing the 
 effectiveness of massage for the shoulder rom . according to the data inclusion criteria based on the picos ( participants , interventions , 
 comparisons , outcomes , and study design ) format , a systematic literature review description 
 format , the participants ( p ) in this study consisted of adults aged 18  years or older with 
 shoulder pain . the intervention ( i ) was massage therapy given alone or in combination with 
 another treatment . the comparisons ( c ) included the control groups that did not receive any 
 intervention or that received placebo or another intervention . the outcomes ( o ) were studies 
 that measured the shoulder flexion , extension , abduction , internal rotation , and external 
 rotation using a standardized instrument . the study design ( s ) was a randomized controlled 
 or non - randomized controlled trial . the exclusion criteria for data analysis were studies including participants 
 diagnosed with infection , neoplasm , fracture , instability , dislocation , hemiplegia , or 
 postoperative or perioperative shoulder pain , and studies in which the mean and standard 
 deviation could not be calculated . in the data search , the studies that had been published until june 2016 were targeted , 
 without imposing any limit on the publication year . the databases that were used for the 
 search were pubmed , cinahl , embase , psycinfo , riss , ndsl , nanet , dbpia , and koreamed . flexion ,   extension ,   abduction ,  
  internal rotation ,   external rotation ,   range of motion ,   functional status ,   muscular 
 function massage ,   therapeutic touch ,   reflexotherapy , reflexion ,   manual ,  
  manipulative ,   clinical trial , the available data were extracted 
 and coded according to the information on the author , publication year , study design , 
 participants , intervention contents , and outcomes measured . the risk of bias was assessed 
 using the grace ( grades of recommendation , assessment , development , and evaluation ) system 
 recommended by the cochrane back review group , where a higher score means a lower risk of 
 bias8 . for the selected papers , the effect size and homogeneity of the studies were analyzed using 
 the revman 5.3 program of the cochrane library . the effect size was presented using the mean 
 difference and the 5% significance level . the homogeneity of the studies was assessed using 
 higgins s i. if homogeneity was ensured , the effect size was calculated with the 
 fixed - effect model , whereas if homogeneity was not ensured , the effect size was calculated 
 with the random - effect model . the first literature search yielded a total of 925 papers , and of these , the 471 duplicate 
 papers that had been obtained in more than two different databases were removed , leaving 454 
 papers . after that , the titles and abstracts of the papers were checked . consequently , of 
 the 454 selected papers , the 377 papers that did not meet the inclusion criteria were 
 excluded , and 77 papers thus remained . lastly , based on the review of the full texts of the 
 77 remaining papers , 7 papers finally met the inclusion criteria based on the picos for 
 meta - analysis ( fig . 1fig . the total number of study participants was 237 ( experimental group : 120 ; control 
 group : 117 ) , and the risk - of - bias scores ranged from 511 points out of 12 points ( m  sd , 
 8.4  2.14 ) ( table 1table 1.characteristics of included studiesfirst author and yearstudy designparticipantsinterventionscompari - sonsoutcomes / methodtotal risk - of - bias scoretotal n ( en / cn)mean of age% of femaletypelocationn . of session / min.follow -upchoi 2004nrct58 ( 30,28)75.274.1kyongrak massagecervical spine5/10-no treatmentflexion , abduction , external rotation / goniometry5dyson - hudson 2001rct18 ( 9,9)45.122.2manual pressure releaseshoulder , upper extremities 10/455 wkacupunc - tureflexion , abduction / goniometry9kim 2016rct6 ( 3,3)50.00.0sports massage , hot packneck , shoulder , back36/20-hot packflexion , extension , abduction , internal rotation , external 
 rotation / goniometry7park 2016nrct30 ( 15,15)49.6100.0sports massageshoulder12/30-no treatmentflexion , extension , abduction , internal rotation , external 
 rotation/ goniometry7son 2013nrct16 ( 8,8)56.5nrsports massage , physical therapyshoulder36/40-physical therapyflexion , extension , abduction , internal rotation , external 
 rotation/ goniometry6van den dolder 2003rct29 ( 15,14)64.031.0soft tissue massageshoulder6/1520-no treatmentflexion , abduction / photography10van den dolder 2015rct80 ( 40,40)62.652.5soft tissue massage , exerciseshoulder , back 7/101512 wkexerciseflexion , abduction/ photography11rct : randomized controlled trials ; nrct : non- randomized controlled trials ; nr : not 
 reported ; en : experimental number ; cn : control number ; exercise : an individualized 
 shoulder exercise program ) . the quantitative duration of massage raged from 1045 minutes ( m  sd , 27.5 
  13.61 ) ( table 1 ) . the effect size for flexion 
 was 18.21 ( 95% ci 1.5734.85 ) ( fig . 2.forest plot of effect size of massage therapy for flexion ) , that for extension was 6.29 ( 95% ci 2.2314.82 ) , that for abduction was 22.07 ( 95% 
 ci 5.8438.30 ) ( fig . 3fig . 3.forest plot of effect size of massage therapy for abduction ) , that for internal rotation was 10.10 ( 95% ci 10.29 , 30.48 ) , and that for external 
 rotation was 9.54 ( 95% ci 2.78 , 21.85 ) . flow diagram of the study selection rct : randomized controlled trials ; nrct : non- randomized controlled trials ; nr : not 
 reported ; en : experimental number ; cn : control number ; exercise : an individualized 
 shoulder exercise program forest plot of effect size of massage therapy for flexion forest plot of effect size of massage therapy for abduction even though massage therapy is the commonly used treatment program for improving the 
 shoulder rom in the clinic , little is known about its efficacy . this study performed a 
 systematic literature review with a meta - analysis of seven studies with a total of 237 
 participants to determine the effect of massage therapy on the shoulder rom . the study results suggested that there is evidence of the efficacy of massage therapy for 
 improving the shoulder rom , especially flexion and abduction . when the massage therapy group was compared with the 
 no - treatment group in the subgroup analysis , the massage therapy group showed a larger 
 effect size in increasing the flexion and abduction of the shoulder joint , but it showed no 
 statistically significant difference in this regard from the acupuncture , hot pack , or 
 physical therapy group . van den 
 dolder et al.7 , who conducted a 
 meta - analysis of 4 papers , found that soft - tissue massage had low - quality evidence in 
 moderately improving the flexion and abduction rom compared to no treatment , but it showed 
 no statistically significant difference in this regard from the other intervention 
 groups . effleurage is rubbing the skin lightly from the distal site to the 
 proximal site using the extremities . it reduces edema and promotes muscle relaxation by 
 facilitating the flow of the lymph nodes . petrissage is performed for the purpose of 
 increasing the movability of the muscle , by twisting the area between the muscle and the 
 skin after holding the soft tissue . friction is pressing the skin soft tissue deeply using a 
 thumb , by putting it on the bone or on the fascia of the muscle10 . these techniques smoothen scar tissue and loosens the 
 deep adhesion in the tendons , ligaments , joint capsules , etc10 . of seven studies examining the effectiveness of massage therapy soft - tissue massage 
 stimulates the trigger points , which are hyperirritable spots in skeletal muscle and are 
 characterized by pain appearing at muscle contraction . the typical trigger points around the 
 shoulder include the rotator cuff , latissimus dorsi , teres major , deltoids , and pectoral 
 muscles13 . soft - tissue massage has also 
 been reported to reduce shoulder pain14 . in three out of seven papers , physiological aging of the musculoskeletal system and joints is one of the important factors 
 of shoulder pain and causes lowered physical activity and exercise ability as well as 
 chronic pain15 . in particular , shoulder 
 pain and shoulder rom limitation causes independent competence disability , including in 
 dressing or hygiene management , which elderly people must conduct by themselves in their 
 everyday lives . elderly people s inability to manage themselves without the help of another 
 person causes their shrinkage and depression , and may have a significant impact on their 
 quality of life16 . therefore , it is 
 thought that massage therapy that increases the shoulder rom can improve the quality of life 
 of elderly people . this study provided insight into the current stage of massage therapy on the shoulder rom , 
 and is a first step in the development of evidence - based intervention recommendations . first , as there have not been many 
 randomized controlled trials ( rct ) , the quality of the studies that were included in the 
 analysis was not high . later , if more papers that conducted rct are collected , meta - analysis 
 will need to be performed . second , the homogeneity of the papers that were included in the 
 analysis was low , and the papers that were included in the analysis were not many ; thus , 
 subgroup analysis for the intervention moderators could not be performed . in the future , the 
 basis of massage therapy that is more effective in improving the shoulder rom needs to be 
 suggested by conducting an analysis of the intervention moderators .
[ purpose ] this study was conducted to identify and analyze the degree of effect of 
 massage therapy on the range of motion of the shoulder . [ subjects and methods ] the 
 database search was conducted using pubmed , cinahl , embase , psycinfo , riss , ndsl , nanet , 
 dbpia , and koreamed . 
 the meta - analysis was based on 7 studies , covered a total of 237 
 participants , and used a random - effects model . [ results ] 
 the effect size estimate showed 
 that massage therapy significantly improved the shoulder range of motion , especially the 
 flexion ( smd : 18.21 , 95% ci 1.5734.85 ) and abduction ( smd : 22.07 , 95% ci 5.8438.30 ) . 
 [ conclusion ] the review findings suggest that massage therapy is effective in improving 
 the shoulder flexion and abduction .