Massage Reduced Severity of Pain During Labour: A Randomised Trial

Gallo et al: Massage for labour pain
Massage reduced severity of pain during labour:

a randomised trial
Rubneide Barreto Silva Gallo1, Licia Santos Santana1, Cristine Homsi Jorge Ferreira2, Alessandra
Cristina Marcolin1, Omero Benedicto PoliNeto3, Geraldo Duarte1 and Silvana Maria Quintana1
1
Department of Gynecology and Obstetrics, 2Department of Health Sciences Applied to the Locomotor Apparatus, 3Department of Surgery and Anatomy
Faculty of Medicine of Ribeiro Preto, University of So Paulo, Ribeiro Preto/SP, Brazil
Question: Does massage relieve pain in the active phase of labour? Design: Randomised trial with concealed allocation,
assessor blinding for some outcomes, and intention-to-treat analysis. Participants: 46 women pregnant at * 37 weeks
gestation with a single fetus, with spontaneous onset of labour, 45 cm of cervical dilation, intact ovular membranes, and
no use of medication after admission to hospital. Intervention: Experimental group participants received a 30-min lumbar
massage by a physiotherapist during the active phase of labour. A physiotherapist attended control group participants
for the same period but only answered questions. Both groups received routine perinatal care. Outcome measures:
The primary outcome was pain severity measured on a 100 mm visual analogue scale. Secondary outcomes included
the Short Form McGill Pain Questionnaire, pain location, and time to analgesic medication use. After labour, a blinded
researcher also recorded duration of labour, route of delivery, neonatal outcomes, and the participants satisfaction with the
physiotherapist during labour. Results: At the end of the intervention, pain severity was 52 mm (SD 20) in the experimental
group and 72 mm (SD 15) in control group, which was signicantly different with a mean difference of 20 mm (95% CI 10
to 31). The groups did not differ signicantly on the other pain-related outcome measures. Obstetric outcomes were also
similar between the groups except the duration of labour, which was 6.8 hr (SD 1.6) in the experimental group and 5.7 hr
(SD 1.5) in the control group, mean difference 1.1 hr (95% CI 0.2 to 2.0). Patients in both groups were satised with the
care provided by the physiotherapist. Conclusion: Massage reduced the severity of pain in labour, despite not changing
its characteristics and location. 5SJBMSFHJTUSBUJPO: NCT01392053. <(BMMP3#4 4BOUBOB-4 'FSSFJSB$)+ .BSDPMJO"$
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Key words: Randomised controlled trial, Labor pain, Massage, Parturition, Obstetric labor
Introduction
Various techniques have been proposed to relieve labour
pain including massage therapy, which, in addition to
promoting pain relief, provides physical contact with the
parturient, potentiating the effect of relaxation and reducing
emotional stress (Kimber et al 2008, Field 2010, Simkin
and Bolding 2004). Several theories have been proposed
to explain the mechanism by which massage might relieve
pain, such as a reduction in cortisol and norepinephrine
levels (Chang et al 2002, Field 2010, Nabb et al 2006), an
increase in serotonin levels (Field 1998), the stimulation of
endorphin release and of the circulation with a consequent
increased oxygen supply for the tissues, and the facilitation
of toxin excretion through the lymphatic system (Zwelling
et al 2006). In addition, Melzack and Wall (1965) proposed
a mechanism whereby the noxious stimuli evoked by lesions
are regulated in the spinal cord by nerve cells that act as
gates, preventing or facilitating the passage of impulses to
the brain.
Some studies have demonstrated the efcacy of massage
during labour. In the USA, Field et al (1997) observed that
a group of women who received massages during labour
presented a less depressed mood, lower levels of pain, stress
and anxiety, and more positive facial expressions. Chang et
al (2002) conducted another study on massage throughout
the active phase of labour and detected a gradual increase
in pain and anxiety in the control and experimental
groups, with lower pain scores during the three phases in

the experimental group, and a lower anxiety score only in
the rst phase, as observed using a visual analogue scale.
Kimber et al (2008) compared three groups of parturients;
one group received massage combined with a relaxation
technique, another received music therapy, and a control
group received the usual maternity care. The authors
observed a tendency toward a reduction in pain in the
massage group, although the difference from the other two
groups was not statistically signicant.
A recent Cochrane systematic review (Smith et al 2012)
included six articles involving 326 women and showed that
massage may have a signicant role in reducing pain and
What is already known on this topic: Several trials

have identied that massage reduces the amount of
pain and anxiety experienced during the rst stage of
labour. However, a systematic review indicates that
these trials are at moderate or greater risk of bias and
pooling their results leads to an imprecise estimate of
the effect of massage on pain during labour.
What this study adds: Thirty minutes of massage
during labour reduced the amount of pain
experienced at the end of the massage signicantly,
although the characteristics and location of the pain
did not change.
Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013 Open access under CC BY-NC-ND license.
109
Research
improving the emotional experience of labour. However,

the pooled data from four trials involving 225 women
that examined the effect of massage on pain generated a
standardised mean difference of 0.82 (95% CI 0.47 to
1.17). This demonstrates that the true effect could be either
a small-to-moderate effect or a very large effect. Also,
among these trials, only one used concealed allocation and
only one registered a study protocol. Therefore, although
several reports demonstrate that massage reduces pain,
further well-designed clinical trials using this modality
applied in a directed and sequential manner for pain
relief during labour are indicated. Therefore, the research
questions for this study were:
1. Does massage relieve pain in the active phase of
labour?
2. Does massage change the characteristics and location
of the pain?
3. Does massage inuence obstetric and newborn
outcomes?
4. Are women in labour satised with the presence of a
physiotherapist to provide massage?
Method
Design
This was a randomised trial with concealed allocation,
assessor blinding of some outcomes, and intention-totreat analysis. After meeting the eligibility criteria for the
study, participants were randomly allocated by the primary
researcher to an experimental group or a control group
according to a computer-generated random allocation list.
During the period of 45 cm of cervical dilation with uterine
contractions, participants in the experimental group received
massage for 30 min by the primary researcher. A secondary
researcher remained blinded to group allocations and was
never present while the experimental or control procedures
were performed by the primary researcher. The secondary
researcher recorded each participants responses regarding
the pain severity, location, and characteristics immediately
before and immediately after the intervention. Blinding
was maintained by the secondary researcher leaving the
room after assessing the pain-related outcomes at baseline,
and returning to reassess the same outcomes after the
intervention. After labour and before hospital discharge, the
secondary researcher collected the data regarding obstetric
and neonatal outcomes, and also recorded the opinion of the
participants regarding the presence of the physiotherapist
during the study period.
1BSUJDJQBOUT UIFSBQJTUT BOEDFOUSFT
Participants were recruited from the women admitted to
the Reference Center of Womens Health of Ribeiro PretoMATER, state of So Paulo, Brazil, between September
2009 and May 2010. This is a 40-bed unit that serves a mean
of 3600 patients per year in Brazils public health system.
The inclusion criteria were: primigravida, a single fetus
in cephalic position, low-risk pregnancy, at least 37 weeks
of gestation, the spontaneous onset of labour, cervical
dilation of 45 cm with appropriate uterine dynamics for
this phase, no use of medication from admission to hospital
until randomisation, the absence of cognitive or psychiatric
problems, intact ovular membranes, literacy, and with
no associated risk factors. The main exclusion criterion
was the presence of dermatologic conditions that would
110
contraindicate the application of massage. Participants

were free to withdraw from the study if they were intolerant
of the allocated intervention or if they declined further
participation at any stage.
The two therapists involved in the intervention and data
collection had both specialised in womens health since
early 2008. Although the standardisation of the methods for
evaluating the pain in labour should have minimised any
interference of the researcher, the therapists took the same
role, ie, the primary researcher conducted randomisation
and the application of the study interventions (massage or
routine care), while the secondary researcher conducted the
measurement of outcomes.
Intervention
The experimental group received massage from a
physiotherapist (the primary researcher) at the beginning
of the active phase of labour, during the period of 45 cm
of cervical dilation and during uterine contractions for 30
minutes. The intensity of the massage was determined by
the participant, who was instructed to request greater or
lesser force during execution of the massage according to
her preference. The technique was applied between T10 and
S4, which corresponds to the path of the hypogastric plexus
and the pudendal nerve, responsible for innervation of the
paravertebral ganglia, delivery canal, and perineum. The
massage consisted of rhythmic, ascending, kneading hand
movements and a return with sliding through the lateral
region of the trunk in association with sacral pressure. The
participants were also instructed to choose their preferred
position for receiving massage, ie, sitting, lateral decubitus,
or standing with the trunk bending forward. This group
also received other routine maternity ward care, discussed
further below.
The control group received the same routine maternity ward
care. In addition, the same primary researcher accompanied
participants in the control group for 30 minutes during
the period of 45 cm of cervical dilation, as done for the
massage group, although the investigator was there merely
for observation and to answer questions.
The routine care of the maternity ward during the period
of dilation is based on the recommendations of the World
Health Organization (WHO 1985) for more humanised
childbirth. After admission to the hospital, a meal was
offered to the participants and resources for pain relief were
permitted, if requested by the participant. Such resources
include labour analgesia and oxytocin when necessary. The
parturient was allowed to choose the most comfortable
position. The presence of an accompanying person was
permitted during labour and delivery as well as during any
other medical procedures.
Outcome measures
Primary outcome: The primary outcome was the change
in pain severity at the end of the intervention period. To
measure this, pain severity was marked by the participant
on a 0100 mm visual analogue scale at the beginning and
end of the intervention period. We considered 13 mm to be
a clinically relevant reduction in acute pain (Bernstein et al
2006, Gallagher et al 2001, Todd et al 1996).
Secondary outcomes: The characteristics of the pain during
labour were assessed using the Short-Form McGill Pain
Women admitted and assessed for

eligibility (n = 249)
Excluded (n = 203)
t multiparous (n = 97)
t cervical dilation > 5 cm (n = 39)
t ruptured ovular membranes (n = 26)
t use of pain medication between
admission and randomisation (n = 31)
t uterine adynamia (n = 4)
t fetus pelvic position (n = 2)
t illiteracy (n = 4)
Measured pain visual analogue scale and McGill Pain Questionnaire

Randomised (n = 36)
(n = 23)
(n = 23)
0 min
Lost to follow-up
(n = 0)
30 min
Post-partum
Experimental Group
t massage by
physiotherapist
between T10 and S4
t 30 min
t usual care
Control Group
t physiotherapist
present only to
answer questions
t 30 min
t usual care
Lost to follow-up
(n = 0)
Measured pain-related outcomes

(n = 23)
(n = 23)
Measured obstetric and neonatal outcomes

(n = 23)
(n = 23)
'JHVSF. Recruitment and ow of participants through the trial.
Questionnaire. This questionnaire results in several outcome

measures that reect the emotional and sensory aspects of
pain. On all of these measures, higher scores reect greater
pain. The number of words chosen to describe the pain is
tallied for sensory words, affective words, and total words.
The estimated pain index combines sensory (033) and
affective (012) scores to give a total score (045). Lastly,
the present pain intensity is rated on a numerical scale (0
= no pain, 1 = mild, 2 = discomforting, 3 = distressing, 4
= horrible, 5 = excruciating). The Short-Form McGill Pain
Questionnaire has been used in several studies (eg, Chang
et al 2006). It combines the properties of the standard
McGill Pain Questionnaire but takes substantially less time
to administer, while using the same descriptive adjectives
(Costa et al 2011).
The location of the pain was recorded using a standard
body diagram. The areas of pain were pointed out by the
participant and marked on the diagram by the secondary

blinded researcher.
Obstetric and neonatal outcomes were also collected by the
secondary blinded researcher. Obstetric outcomes included
the duration of labour, the time taken for the participant to
request pain medication after the end of the intervention
period, and the path of delivery. Neonatal outcomes were
weight, length, head circumference, chest circumference,
and APGAR score. After labour, each participant was asked
to answer a few questions regarding their satisfaction with
the care provided and the presence of a health professional
during the study.
The posture adopted by each participant during the
intervention was recorded by the primary researcher. More
than one position could be recorded.
111
Research
5BCMF Characteristics of the participants.

Characteristic
Data analysis
To determine the required sample size, pilot testing was
carried out with 16 parturients to determine the standard
deviation of pain severity on the visual analogue scale.
We sought an effect on pain of about 13 mm on a visual
analogue scale. Using the standard deviation of 15 mm
from our pilot data, a signicance level of 5% and a test
power of 80%, we calculated that we needed a minimum
of 22 participants in each group. To allow for some loss to
follow-up, we recruited 46 participants.
Randomised
(n = 46)
Exp
(n = 23)
Con
(n = 23)
Age (yr), mean (SD)
19 (3)
19 (4)
Body mass index

(kg/m), mean (SD)
28 (4)
27 (3)
elementary school
8 (35%)
6 (26%)
high school
14 (61%)
17 (74%)
1 (4%)
0 (0%)
voluntary work
16 (70%)
17 (74%)
paid work
7 (30%)
6 (26%)
Education, n (%)
higher education
For pain assessment, a comparative analysis was performed

between the experimental and control groups using a
linear regression model with mixed effects (random and
xed effects). For dichotomous outcomes, the differences
between groups are presented as relative risk with 95% CI.
Occupation, n (%)
None of the participants used analgesic medication during

the time from admission to hospital until the end of the reevaluation of the pain-related outcomes after the intervention
period. This allowed the data from all participants to be
included in the analysis of pain outcomes without a possible
confounding effect of analgesic medication use.
Marital status, n (%)

single
7 (30%)
7 (30%)
married
7 (30%)
3 (13%)
consensual union
9 (39%)
13 (57%)
Accompanied by a
family member, n (%)
23 (100%)
23 (100%)
Childbirth preparation
course, n (%)
7 (30%)
6 (26%)
'MPXPGQBSUJDJQBOUT UIFSBQJTUTBOEDFOUSFT
through the study
The ow of participants through the trial is shown in Figure
1. In total, 249 parturients were screened and 203 were
excluded for not meeting the inclusion criteria. Forty-six
participants were included in the study and were divided
into the experimental group (n = 23) or the control group
Results
Uterine dynamics, n (%)

DPOUSBDUJPOTNJO
8 (35%)
6 (26%)
DPOUSBDUJPOTNJO
13 (56%)
15 (65%)
DPOUSBDUJPOTNJO
2 (9%)
2 (9%)
5BCMF. Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI) difference between groups for pain
outcomes.
Groups
0 min
Pain VAS (mm)
30 min
Difference within
groups
Difference between
groups
30 min minus 0 min
30 min minus 0 min
Exp
(n = 23)
Con
(n = 23)
Exp
(n = 23)
Con
(n = 23)
Exp
Con
Exp minus Con
69
(15)
69
(17)
52
(20)
72
(15)
17
(14)
3
(16)
20
(10 to 31)
6
(2)
3
(1)
9
(2)
6
(2)
2
(1)
8
(2)
6
(2)
2
(1)
8
(2)
6
(2)
2
(1)
8
(3)
0
(1)
1
(1)
1
(2)
0
(1)
0
(1)
0
(2)
0
(1 to 1)
0
(1 to 1)
0
(2 to 1)
16
(6)
7
(4)
23
(8)
3.6
(0.4)
15
(5)
6
(3)
21
(8)
3.4
(1.0)
13
(6)
5
(4)
18
(8)
2.7
(1.3)
15
(7)
6
(3)
21
(9)
3.3
(1.1)
3
(5)
2
(3)
5
(7)
0.9
(1.2)
0
(4)
0
(2)
1
(6)
0.2
(1.0)
3
(7 to 1)
1
(3 to 1)
3
(8 to 3)
0.6
(1.3 to 0.1)
Number of words chosen

Sensory (n)
Affective (n)
Total (n)
Estimated pain index
Sensory (0 to 33)
Affective (0 to 12)
Total (0 to 45)
Present pain intensity (0 to 5)
Exp = experimental (massage) group, Con = control group, VAS = visual analogue scale, Shaded row = primary outcome
112
5BCMFMean (SD) for each outcome in each group and mean difference (95 % CI) between groups for continuous
obstetric and neonatal outcomes.
Outcome
Duration of labour (hr), mean (SD)

Time to pain medication after the end of the
intervention (hr), mean (SD)a
Newborn weight (kg), mean (SD)
Newborn length (cm), mean (SD)
Newborn head circumference (cm), mean (SD)
Newborn chest circumference (cm), mean (SD)
Groups
Mean difference between

groups
Exp
(n = 23)
Con
(n = 23)
Exp relative to Con
6.8
(1.6)
2.6
(1.3)
3.30
(0.47)
49.6
(2.0)
34.5
(1.3)
33.2
(2.0)
5.7
(1.5)
1.9
(1.2)
3.17
(0.35)
49.3
(1.7)
34.5
(1.7)
33.1
(1.7)
1.1
(0.2 to 2.0)
0.7
(0.1 to 1.5)
0.13
(0.11 to 0.37)
0.4
(0.7 to 1.5)
0.0
(0.9 to 0.9)
0.1
(1.0 to 1.2)
Exp = experimental (massage) group, Con = control group, aOne participant did not use analgesic medication in each group.
(n = 23). The characteristics of the participants in each

group are presented in Table 1. The groups were similar
with regard to demographic details, prenatal preparation,
and uterine dynamics. No participant asked to leave the
study before completion.
and 15 (65%) participants in the control group reported

suprapubic and lumbar pain, with no signicant difference
between groups (RR = 0.87, 95% CI 0.54 to 1.38). Therefore,
massage did not change the characteristics or the location of
the pain in the active phase of labour.
Compliance with trial method
The mean duration of labour was longer in the experimental

group by 1.1 hr but this was of borderline statistical
signicance (95% CI 0.2 to 2.0). The mean time to pain
medication was 2.6 hr (SD 1.3) in the experimental group
and 1.9 hr (SD 1.2) in the control group. However, this was
not statistically signicant, with a mean difference of 0.7
hr (95% CI 0.1 to 1.5). The anthropometric measures of
the newborns were not signicantly different between
the groups. All these data are presented in Table 4, with
individual patient data presented in Table 3 (on the
eAddenda.)
Each participant received the intervention that was

randomly allocated to her. There was no loss to follow-up
of participants for any reason. The secondary researcher
remained unaware of which intervention each participant
received.
Effect of intervention
On the visual analogue scale of pain severity, the
experimental group improved by a mean of 17 mm (SD
14) from baseline to the end of the intervention. The
control group showed a small rise in pain intesity of 3 mm.
Therefore the effect of massage can be estimated as 20 mm
(95% CI 10 to 31) on the visual analogue scale, as presented
in Table 2. Individual patient data are presented in Table 3
(see eAddenda for Table 3.)
On the McGill Pain Questionnaire, the words frequently
used by the participants to describe their pain during labour
were: cramping, aching, and tearing (from the sensory
aspect), and tiring/exhausting (from the affective aspect).
The range of words used to describe the pain was similar
in both groups, before and after the procedure. There were
no statistically signicant differences between the groups
in terms of the number of words chosen, the estimated pain
index, or present pain intensity. These data are presented in
Table 2, with individual patient data presented in Table 3
(on the eAddenda.)
Using a body diagram before the intervention, most
participants, 20 (83%) in the experimental group and 16
(70%) in the control group, indicated that their pain was
present in the suprapubic and lumbar regions. At the end
of the intervention period, the groups were again similar.
Thirteen (57%) participants in the experimental group
The participants in the massage group were more likely to

adopt a sitting position during the intervention period than
those in the control group (RR = 1.8, 95% CI 1.1 to 3.0).
Path of delivery was unaffected by the intervention, with
six Caesarean deliveries in the experimental group and four
in the control group (RR = 1.5, 95% CI 0.5 to 4.6). Around
90% of the newborns in both groups had normal APGAR
scores by the rst minute after delivery, and all had normal
APGAR scores by the fth minute after delivery. All these
data are presented in Table 5, with individual patient data
presented in Table 3 (on the eAddenda.)
Regarding satisfaction with the attending physiotherapist,
all participants stated that the quality of care received
during labour was important. The intervention was rated
as excellent by 65% of the experimental group and 70%
of the control group. Sixteen participants (70%) in the
experimental group and nine (39%) in the control group
reported that the intervention they received promoted the
relief of pain, stress, and anxiety during the active phase
of labour. All participants in the experimental group and
96% in the control group stated that they would like to
receive the same care in future childbirths. None of these
differences reached statistical signicance.
113
Research
5BCMF. Number of participants (%) for each outcome in each group and relative risk (95% CI) between
groups for dichotomous obstetric and neonatal outcomes.
Outcome
Groups
Relative risk
(95% CI)
Exp
(n = 23)
Con
(n = 23)
Exp relative to Con
18 (78)
10 (43)
Lateral decubitus
4 (17)
1 (4)
Dorsal decubitus
Sitting and dorsal decubitus
0 (0)
1 (4)
9 (39)
1 (4)
Sitting and lateral decubitus

Lateral and dorsal decubitus
Path of delivery, n (%)
0 (0)
0 (0)
1 (4)
1 (4)
1.8
(1.1 to 3.0)
4.0
(0.5 to 33.1)
1.0
(0.1 to 15.0)
Caesarean delivery
6 (26)
4 (17)
Vaginal delivery
17 (74)
19 (83)
> 7 at rst minute
21 (91)
20 (87)
> 7 at fth minute
23 (100)
23 (100)
Position adopted during intervention, n (%)

Sitting
1.5
(0.5 to 4.6)
0.9
(0.7 to 1.2)
APGAR Score of newborn (0 to 10), n (%)

1.1
(0.9 to 1.3)
1.0
(1.0 to 1.0)
Exp = experimental (massage) group, Con = control group
Discussion
Labour pain is progressive, with rapid alterations of its
location and an increase in severity with advancing dilation
and intensity of uterine contractions (Melzack et al 1981). In
the rst stage of labour, pain is located in the lower portion
of the abdomen and radiates to the lumbar area, increasing
with the intensity of uterine contractions (Mamede et al
2007, Sabatino et al 1996). In the present study, we observed
that during the active phase of labour, the pain was located
mainly in the lumbar and suprapubic regions, in agreement
with these reports.
Massage during the active phase of labour signicantly
reduced pain reported on the 100 mm visual analogue scale,
with a mean effect of 20 mm, which exceeded the minimum
clinically important difference of 13 mm. Although the
lower limit of the 95% CI was slightly below the minimum
clinically important difference, clinically worthwhile mean
estimates have been obtained by other authors in this area,
such as Chang et al (2002) who observed a reduction of 16
mm for the massage group compared to the control group
in the presence of 35 cm of cervical dilation (p < 0.05).
Taghinejad et al (2010) also detected a substantial reduction
in labour pain (p = 0.001) in participants receiving massage
compared to a music therapy group. Therefore our study
adds support to the notion that the effect of massage on pain
may be clinically worthwhile.
On the McGill Pain Questionnaire, we observed that the
words pricking, cramping, aching and lacerating most
commonly characterised the sensory aspect of labour pain,
114
and the words tiring, exhausting and nauseating most

characterised the affective aspect in both groups and both
before and after the procedure. This is in agreement with
the study by Chang et al (2006), who evaluated the effect of
massage on labour pain using the same instrument. Other
studies also detected the words acute, cramping, aching,
stabbing and palpitating as characterising labour pain
(Brown et al 1989, Melzack et al 1981). We did not detect
signicant differences between the groups in the number of
words chosen, the estimated pain index, or the present pain
intensity on the McGill Pain Questionnaire, suggesting that
massage does not modify the characteristics of pain.
Massage had no adverse effects on the path of delivery or the
status of the newborn. Although we identied an increase in
the duration of labour, this appears to be a chance nding
because it was of borderline statistical signicance and
because no signicant effects on labour duration were
found in other studies of massage during labour (Chang et
al 2002, Kimber et al 2008). During the intervention period,
women in the experimental group were more likely to adopt
the sitting position, which probably only reects that this
is a more convenient position in which to receive massage.
The perception and methods of coping with labour pain
are determined by the subjective characteristics of each
parturient and are inuenced by the hospital environment
and the emotional support received (Campbell et al 2006,
McGrath and Kennell 2008). A systematic review by Hodnett
et al (2008) demonstrated that continuous intrapartum
support reduces the duration of labour and the probability
that the parturient will receive analgesia and will report
dissatisfaction with her experience. Massage differs from

the other techniques because it permits direct contact with
the parturient by another person. Thus, while the procedure
is applied, the parturient also receives emotional support.
Colloca and Benedetti (2009) report that the expectations
associated with some procedures can inuence markedly
the response to these interventions, in both positive and
negative terms. Placebo responses are not limited to placebo
interventions and treatments of proven efcacy may also
generate such responses, increasing the therapeutic benet of
treatment (Colloca and Miller 2011, Lui et al 2010). Massage,
in addition to producing therapeutic effects physiologically,
may also generate placebo responses, which can occur by
means of observational learning in a social context, with
no deliberate reinforcement. Although physiological and
placebo effects can be difcult to distinguish, our study was
able to highlight the overall therapeutic effect of massage
on labour pain while controlling for the effects of attention
because of the continuous support received by both groups.
In the present study, there were limitations inherent to the
investigation itself and to the environment in which it was
conducted, despite efforts to minimise the inuence of
these effects on the participants. For example, the inuence
of the pain of other women in labour or under the effect
of childbirth analgesia in the same environment as the
participants, and the fact that participants were informed
about the study may have elicited expectations about pain
relief after application of the intervention. The simple act
of touching or giving words of support may also generate
placebo responses, as discussed above. There are also
socially recognised factors that may generate negative
placebo responses, such as childbirth analgesia offered
by the maternity staff, causing the parturients to tolerate
less pain; negative experiences of relatives and/or friends;
parturients and accompanying persons with no physical
or emotional preparation, which may limit the amount of
support the accompanying person can give; and even the
Brazilian culture, which associates pain with suffering and
wishes to eliminate it.
On the basis of the results of the present study, we trust
that massage will be encouraged by the health professionals
who assist women in labour, because this intervention
is easily applied and it contributes to the management of
pain, facilitating reduced reliance on analgesic medications.
Additionally, massage can be offered by the accompanying
person after training during the prenatal courses,
underscoring the need for humanised and interdisciplinary
care, with effective support for women during this phase. Q
eAddenda: Table 3 available at jop.physiotherapy.asn.au
Thanks are also due to CNPQ, who provided the masters

degree scholarship and aided in the development of this
study.
Correspondence: Silvana Maria Quintana, Departamento
de Ginecologia e Obstetrcia, Faculdade de Medicina de
Ribeiro Preto da USP, BRAZIL. Email: quintana@fmrp.
usp.br
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