By Shirley Vanderbilt
Originally published in Massage & Bodywork magazine, August/September 2005.
Over the past two decades, reports on the worldwide HIV/AIDS epidemic have been splashed across our newspapers and delivered to us by newscasters in daily doses. Although the initial shock has worn off for many Americans, the epidemic is thriving with devastating impact in poor, developing countries. Take a moment to consider the following information released by the United Nations (U.N.) in its 2004 global report.
Of the nearly 40 million people living with HIV (human immunodeficiency virus), 2.1 million are children. “More than 1,900 children worldwide are infected with HIV each day,” the report states. The majority of these children are infected in the womb, during childbirth, or as a result of breast-feeding by an infected mother. Added to this is the estimation that approximately 1,350 children died of AIDS (acquired immunodeficiency syndrome) per day in 2003 (about 490,000 total).1
According to the World Health Organization (WHO), access to antiretroviral treatment (ART) is a major challenge for 5 million to 6 million HIV-infected people in low- and middle-income countries. At the end of 2003, only an estimated 400,000 people had access to ART. This number climbed to 700,000 by the end of 2004, due to increased UN efforts.2 Although encouraging, this still leaves nearly 90 percent of the HIV population in need.3
The report states that treatment for children is especially challenging. “Few HIV medicines are produced in pediatric formulations, and those available as syrups have limitations. They have a short shelf life, children sometimes object to the taste, care providers may have difficulty measuring out the correct doses, and they remain very expensive.”4
While the Third World awaits the results of intensified efforts by the U.N. and others to bolster treatment programs, the plight of these children and the millions of infected adults remains one of a compromised immune system with the potential for developing AIDS and a host of accompanying diseases.
Over the past decade, teams at Touch Research Institute(TRI) in Miami, Fla., have conducted several studies investigating the effects of massage therapy on immune system function in HIV-positive children and adults. With each study has come a strengthening of evidence, the most notable in a recent report published in the Journal of Alternative and Complementary Medicine (December 2004). Conducted in the Dominican Republic, the study offers significant encouragement regarding the use of massage therapy as an alternative immune booster, especially to children without access to HIV drugs.
HIV and Immunity
To better understand the results of the TRI studies, let’s take a brief look at the effects of HIV on the body’s cells, specifically those that fight infection. A key marker of HIV progression is the decline of CD4 positive (CD4+) T cells — the immune system’s “helper” cells. (The subset of lymphocytes known as T cells are so called because their final stage of development occurs in the thymus.5) HIV’s propensity is to attach to CD4 cells, and when these cells mobilize to fight infection by replicating, more HIV copies are made.6 The CD4 cells are now infected and disarmed, which in turn disables other parts of the system, such as communication that stimulates B cells (for antibodies) into action.7
CD8+ T cells (cytotoxic or suppressor cells) are also thought to be involved, with research showing they are likely mobilized in defense against HIV replication.8 Another marker of HIV is the ratio of CD4 to CD8 cells, an indicator of immune status. A healthy ratio is about one to two CD4 cells to every CD8 cell. Although values range from one individual to another, typically in HIV infection there is a dramatic drop not only in CD4 count, but also in the CD4-to-CD8 ratio, indicating a serious depletion of T-helper cells.9,10
CD4 cell counts normally range from 500 to 1,600 (1,000 average) per cubic millimeter of blood.11 According to Centers for Disease Control and Prevention (CDC) standards, a CD4 count below 200 (along with other symptoms) defines progression to AIDS, the most advanced stage of HIV-infection. At this stage, immune depletion is set and life-threatening opportunistic infections take over.12
Enhancing Immunity with Massage
The power of massage therapy to induce relaxation, decrease anxiety, and decrease stress hormones has been well documented in research, particularly that from TRI. While these effects are also an integral part of HIV studies, our main focus here will be on the specific markers of HIV cellular activity.
In 1996, the team of Ironson et al. published a study of 29 gay men (20 HIV+ and 9 HIV-) who received one month of 45-minute massages, Monday through Friday each week. Subjects were studied in two cohorts, the first comprised of 10 HIV+ and 10 HIV- men. In the second cohort, 13 HIV+ participants served as their own controls (within-subject design) with an alternate month of no massage in comparison to the experimental intervention.13
While results showed the anticipated decrease in anxiety and cortisol levels, there was no effect shown on measures of CD4 and CD4-to-CD8 ratio. However, an increase in natural killer cells (NK, another cytotoxic lymphocyte that fights virus and tumors) and CD8 cells did suggest an increase in cytotoxic capacity. As the team points out, NK cytotoxicity is important in fighting opportunistic diseases to which the HIV+ person becomes susceptible.14
Following Ironson’s study, Diego et al. utilized an increased trial period in a study of massage therapy for a group of 24 HIV+ adolescents (2001). Surmising that Ironson’s treatment period was perhaps too short to have an effect on the CD4 and CD4-to-CD8 ratio markers, Diego’s team extended massage treatment to three months, shortening the sessions to 20 minutes, twice weekly, and changing to a less intensive chair massage rather than full-body table massage. In contrast to Ironson’s within-subject design, participants were randomized to a massage therapy or relaxation control group in equal numbers.15
The adolescents were primarily female (n=22) and had a mean CD4 number of 466 with no differences in their HIV treatment regimen. Relaxation therapy for the control group was administered in the same 20-minute, twice-weekly structure as massage, consisting of a guided progressive muscle relaxation routine conducted by either a research assistant or massage therapist. For both groups, a different therapist/assistant was used for each session.16
In addition to design changes in this study, researchers note a higher incidence of depression in the adolescent group might account for the improved results in immune markers found at end of trial. There was a significant increase in NK cells, as well as increases in CD4 cells and improvement in CD4-to-CD8 ratio for the massage group only. Although both groups reported a decrease in anxiety (State Anxiety Inventory), only the massage group’s scores on the depression scale (Center for Epidemiological Studies — Depression Scale) reflected a decrease. The authors note that research has linked depression to immunosuppression “through the effects that epinephrine and norepinephrine have on immune function, including decreased CD4 number and CD4-to-CD8 ratio.” Thus improvement in T-lymphocyte activity, as well as increase in NK cells, could be attributed to the effects of massage on the adolescents’ anxiety and depression. The team recommends a similar trial with HIV adolescents who are not depressed.17
In contrast to the studies of Ironson and Diego, it’s important to note results from Birk et al. in 2000 (Wayne State University and Rehabilitation Institute of Michigan) in which less frequent massage (once weekly) showed no effect on immune measures. Although the study appears to have several confounding factors affecting the outcome, the authors point to this infrequent administration, as compared to Ironson’s protocol, as a likely restriction on the potential of massage to affect at least the NK cell count by attenuating anxiety.18
TRI’s recent preliminary report by Shor-Posner et al. offers the most encouraging HIV results to date regarding the effects of massage on CD4 number and CD4-to-CD8 ratio counts. In the randomized trial of 24 HIV+ children, aged 2–8 years, massage subjects (n=10) received 20 minutes of twice-weekly treatment for 12 weeks. The control group (n=14) met with a nurse or therapist for a friendly visit (including reading, talking, and playing games) according to the same time and frequency structure as massage. Trained nurses administered the massage — “moderate pressure stroking and kneading of muscles, using a non-scented oil.” Intervention protocols were conducted in the Dominican Republic, with blood samples for immune measures flown within 24 hours of sampling to a Miami laboratory for assessment.19
The majority of children had a CD4 cell count higher than 500 (mean 850) and none were on ART. Immunological suppression was reported as: none (Stage 1) in 43 percent of controls and 40 percent of massage group; moderate (Stage 2) in 36 percent of controls and 60 percent of massage group; and severe (Stage 3) in 21 percent of controls. The authors state, “Despite differences in CDC stage distribution, the mean CD4 cell count at baseline was similar” among the groups (massage 802, control 885), with the control group having a significantly higher baseline CD8 count (massage 1,440, control 2,722).20
The change in these numbers, following the 12-week intervention, is compelling and “indicates for the first time that massage therapy appears to have a positive impact on immune function in HIV+ children not receiving antiretroviral medications,” the team writes. CD4 and CD8 cell counts increased for the massage group, while declining for the controls. There was a more extensive overall lymphocyte loss of T cells in the control group, along with a 5 percent decrease in B cells in 43 percent of this group as compared to 20 percent of the massage group.21
The management of HIV and prevention of its progression to AIDS depends heavily on preservation and support of the immune system. These studies from TRI indicate that massage therapy may be an effective tool in boosting immune markers, offering a glimmer of hope in the wake of this devastating epidemic.