Anna Hanus, LMT,1* Sarah Fogarty, PhD2
1Arizona School of Integrative Studies, Prescott, AZ, USA,
2School of Medicine, Western Sydney University, NSW, Australia
Dear editor,
We thank the author/s for their thoughtful and considered engagement with our case report, “The effects of massage therapy on post-traumatic stress disorder.” We appreciate their recognition of the timeliness of exploring massage therapy as a potential supportive intervention for individuals living with post-traumatic stress disorder (PTSD), and we welcome the opportunity to respond to the methodological points they have raised.
We agree that the retrospective case report design inherently limits causal inference; however, it is also important to note that prospective case reports similarly do not allow for causal conclusions. Limited inference is intrinsic to case study methodology, regardless of whether data are collected retrospectively or prospectively.( 1,2) As intended, this report was neither designed nor presented to establish efficacy. Rather, its purpose was to describe clinical observations within a student clinic setting, to potentially generate hypotheses, and to contribute preliminary insights to a relatively underexplored area of massage therapy literature, namely, documented clinical observations arising from student training environments.
We believe it is essential that researchers select study designs that are appropriate to the research question being asked. While randomized controlled trials (RCTs) are undoubtedly a critical methodology for advancing the evidence base, we suggest that moving directly from student clinic observations to an RCT represents a step that may be premature. There are numerous important research questions in the area of massage therapy and PTSD that can be meaningfully addressed using a range of rigorous methodologies prior to, or alongside, randomized trials. Although it is beyond the scope of this response to enumerate all such approaches, we strongly support the use of robust study designs that are well matched to the study aims and research questions in future investigations.
With respect to acknowledging limitations, rather than reiterating the well-established, general limitations of case reports, we chose to focus on those limitations specific to this particular case and its clinical context. Throughout the manuscript, care was taken to avoid implying causality in the interpretation of findings.
Regarding outcome measurement, we acknowledge the limitations of the Generalized Anxiety Disorder 7 (GAD-7) in capturing the full breadth of PTSD symptomatology. The GAD-7 was selected because it was routinely used in the clinical setting at the time of treatment and aligned with the client’s primary presenting concern of anxiety. Importantly, this case report took place within a student clinic environment and involved a student massage therapist with no formal research training. The intent was not to assess the complexity of PTSD, but rather to document the client’s presenting physical and anxiety-related symptoms within the constraints and scope of student clinical practice.
It is beyond the remit of this case report to recommend PTSD-specific outcome measures such as the PTSD Checklist (PCL) or the Clinician-Administered PTSD Scale (CAPS). The CAPS, for example, is designed to be administered by clinicians or trained researchers with a working knowledge of PTSD, requires specific training, takes approximately 45–60 min to administer, and includes diagnostic objectives related to determining current or lifetime PTSD status.(3) Administering an instrument with diagnostic capacity is not appropriate for most massage therapists and is particularly unsuitable within a student massage therapy context.
Furthermore, we contend that the administration of any PTSD-specific assessment tool necessitates that the practitioner be trauma-aware or trauma-informed and possess the requisite training, confidence, resources, referral pathways, and professional supports to respond appropriately to the information disclosed. These requirements are essential to ensure client safety and ethical practice.
It is beyond the scope of a clinical case report to prescribe outcome measures for future studies. Each investigation will have distinct aims, hypotheses, and contexts that should guide the selection of outcome instruments most appropriate to the research question being addressed.
The author/s also raise an important point concerning the examination of different massage techniques and their potential differential effects on PTSD symptoms. While the case report notes the client’s preferences, it was beyond the scope of a single case to systematically evaluate modality-specific outcomes. We agree that comparative and mechanism-focused research exploring how distinct massage approaches may influence specific PTSD symptoms represents an important direction for future work.
Finally, long-term follow-up is uncommon in case reports. The short-term nature of the observed outcomes reflects the practical constraints of clinical case documentation rather than any assertion of sustained benefit. While we agree that longer-term follow-up is important for understanding the durability and clinical relevance of massage therapy interventions, this was not feasible within the context of this case report, which was conducted in a student clinic setting where ongoing follow-up was not part of the treatment or educational framework.
We would also like to address the wording used by the letter’s authors that suggests “understanding the long-term effects of massage therapy is essential for determining its clinical utility in treating PTSD.” We wish to reiterate that this case report did not aim to treat PTSD, nor to evaluate massage therapy as a treatment for PTSD. As such, it would be beyond the scope of this report to make claims or recommendations regarding massage therapy as a treatment for PTSD.
Determining the clinical effectiveness and utility of massage therapy for individuals living with PTSD requires consideration of a broad range of factors, including, but not limited to, access, cost and affordability, equity, safety, trauma-informed practice, quality of life, the nature and type of trauma, and the broader health-care context. These considerations extend well beyond what can be addressed within a single clinical case report and was neither possible nor productive to attempt to encompass them all within the manuscript.
In conclusion, we appreciate the authors’ constructive critique and their emphasis on methodological rigor. We view this case report as an early contribution intended to stimulate dialogue, inform future study design, and encourage further research into massage therapy as a supportive intervention for individuals with PTSD. We share the authors’ hope that future studies will build on this work through robust designs, appropriate outcome measures, modality-specific investigation, and longitudinal assessment.
Sincerely,
Anna Hanus and Sarah Fogarty
Sarah Fogarty is a practicing massage therapist. Anna Hanus has no conflicts of interests to declare.
1. Retrospective case study. In: Mills AJ, Durepos G, Wiebe E, eds. Encyclopedia of Case Study Research. Thousand Oaks, CA: SAGE Publications, Inc.; 2010:825–827. https://doi.org/10.4135/9781412957397.n303
2. Green J, Hanckel B, Petticrew M, Paparini S, Shaw S. Case study research and causal inference. BMC Med Res Methodol. 2022;22(1):307. https://doi.org/10.1186/s12874-022-01790-8
Crossref PubMed PMC
3. PTSD: National Center for PTSD. Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Department of Veterans Affairs; 2025. Available from: https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp. Accessed January 11, 2026.
Corresponding author: Anna Hanus, 1801, Pony Soldier Rd, Prescott, AZ 86303, USA, E-mail: wetarhanus@aol.com, Tel: +1-928-925-3970
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Published under the CreativeCommons Attribution-NonCommercial-NoDerivs 3.0 License.
International Journal of Therapeutic Massage and Bodywork, Volume 19, Number 1, March 2026