Research


RESEARCH


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Evidence Based Practice

The conscientious, explicit and judicious use of current best evidence about the care of individual patients’ Sackett et al (1997).

Massage techniques have been developed and passed on as part of an oral tradition for millennia, but it is only in the last few decades that research, using sophisticated methods of scientific analysis, has been used to test this collective wisdom.

Should we only use techniques that have been thoroughly tested and researched?

This was addressed by Smith and Pell(2003) in an amusing paper on ‘Parachute use to prevent death and major trauma related to gravitational challenge’. Their tongue in cheek argument is that there is very little research evidence on the effectiveness of parachutes. The evidence is almost exclusively anecdotal and single case reports. Bearing this in mind, should the use of parachutes be banned until high quality trials have been completed utilising control groups and placebos? Fortunately we don’t need research, involving randomised trials, to know that parachutes are a very good idea and I for one wouldn't want to be in the placebo group!

It is important to distinguish between ‘Research’ and ‘Evidence’ as they are not necessarily the same thing. Evidence can come from more than research findings; your own personal experience as a therapist is an important source of evidence, patient feedback and the local context in which you work are all recognised as important factors and sources of evidence. It is direct involvement and exposure to real world situations that distinguishes an expert from the novice.


Evidence-based practice is about using the best evidence available to you, to promote the effective care of patients to the best of your ability.

Research is the systematic investigation and scrutiny of a subject using the scientific method and contributes towards the development of massage theory and practice in a number of ways:

Scientific research is advancing our understanding of how the musculo-skeletal system works and what causes it to become dysfunctional.

Research tests the validity and effectiveness of massage therapy in the treatment of specified medical conditions.

Research is starting to reveal how various massage techniques actually work, and is dispelling some long held beliefs and myths.

By systematically documenting and comparing the results of different treatment protocols we can refine the techniques used and direct best practices in the profession.

Investigating and analysing adverse effects helps with the creation of safety guidelines.

Massage research advances the status, generates awareness and promotes the profession to the public and to the health care community, including policy makers.

Massage research is proving to be exciting but tends to be overblown and overstated in the press. As the profession moves towards an ‘evidence based’ approach it is important that therapists distinguish between stronger and weaker levels of evidence and interpret them correctly.


David and Charlotte run the Muscle Clinic and have written a short CPD course on Massage Research available at www.nim-online.com



THE ART & SCIENCE OF MASSAGE

by Chris Caldwell, NAMMT(RMAdv)

Principal of the Northern Institute of Massage


Evidence based or evidence supported?

As recently as fifteen years ago, when the phrase “evidence based” was entering the complementary therapies language, eminent figures in the massage profession were arguing that you could not do research into massage treatment because of the many variables from therapist to therapist, individual use of treatment techniques, the great differences between patients and so on. “Evidence based” caught on and assumed the bench mark upon which treatments were approved or discarded by some.

Research and Massage

Research also caught on; our eyes at the Northern Institute of Massage were opened by Professor Len Goldstone, Professor of Health Professions Research at University of London South Bank. The Professor turned up on our doorstep in Bury and announced himself and thus began his great contribution to the education of Northern Institute students over the next ten years. He started from a position of strength, for as well as his professorship, he was also a massage therapist and a former student at the Northern Institute. Research was and is possible and the Northern Institute has participated in several projects including “Massage and low back pain patients.” (Heron and Kay 2008) and “Hand and Arm massage treatments benefit arthritis sufferers.” (Stuttard 2006).

Current Thoughts

Preference for massage treatment (mostly paid for out of pocket rather than by insurance) is, according to Hannon*(2011), often preferred to other manual treatments (and he listed seven research projects in supported of this observation).

The most important asset that the best massage therapists have, in Hannon’s opinion, is their ability to sense what is right for their patients. Massage reaches its potential when practitioners find passion and devotion to being of service. Empathy and communication are needed to inspire those we treat. Massage treatment rooms have comfortable, well-padded treatment tables, our approach to patients is welcoming and positive designed to encourage relaxation and feelings of security.(e.g. the towel routine as taught at the very first class at the Northern Institute).

Treatments can last up to an hour and this gives every opportunity for the practitioner to really get to know the patient and use his/her skills to create the healing environment (Mosley, BBC TV 2011) in which the patient begins to get better, to improve. Hippocrates wrote about the importance of relaxation in the healing process many centuries ago.

The Northern Institute Diploma

The diplomas awarded by the Northern Institute since 1924 have always used the words “…the art and science of massage..” and a good practitioner has both aspects. Science backs-up, supports the treatments and, fortunately, there are now hundreds of research projects from around the world that offer this support, offering science to the art.

“Massage is a craft, an art acquired by long and thorough study, by long and extensive experience.”

Ken Woodward in a Northern Institute course supplementary booklet “The Skill of Massage” 1980

Reference:

John C Hannon, D.C. “Without science, there must be art.”

Journal of Bodywork & Movement Therapies Vol15 No2 April 2011



Research Studies and evidence-based literature

The following abstracts and references are intended to give members a brief outline of the current developments and findings in Massage and the world of Complementary Medicine. The list does not include all the literature available on the subject of massage but does give a flavour of what is happening in the research world. It is intended to help members consider how research and evidence may influence practice.

Pauline Matthews (CPD Member)


Eisensmith L.P ( 2007) Massage therapy decreases frequency and intensity of symptoms relating to temporomandibular joint syndrome in one case study. Journal of Bodywork and Movement Therapies 11, 223-230

The study investigated the ability of massage therapy to mitigate the frequency and intensity of headaches, jaw clicking and masticatory pain associated with temporomandibular joint syndrome (TMJ) The study was done with one client, a 22 year old officer in the armed forces. Massage techniques combined with strain and counterstrain techniques were administered for 30 minutes twice a week over a 3 week period. Results showed that intensity and frequency of pain in the jaw decreased and jaw opening increased by a third.


Kalamir et al (2007) Manual therapy for temporo-mandibular disorder: a review of the literature Journal of Bodywork and Movement therapies 11, 84-90

This review of published materials and studies regarding treatments of TMJ dysfunction includes massage, electrotherapy and manipulative therapy. The review comments that all 3 therapies are viable and cost effective in the treatment of TMJ compared to other forms of treatment. It is likely that these forms of treatment will become more popular in the future due to their cost-effective nature.


Latifes V et al ( 2005) Fathers massaging and relaxing their pregnant wives lowered anxiety and facilitated marital adjustment.

Journal of Bodywork and Movement Therapies 9, 277-282

This study involved 175 expectant fathers who were assigned to one of three groups

1. Massage therapy, 2. Relaxation therapy, 3. Control group

The massage techniques were taught to the fathers by a licensed therapist and given to the pregnant women twice weekly during the course of the pregnancy. The relaxation group learned some relaxation techniques with their wives and the control group had no intervention. The massage group was found to have lowered the fathers’ self reported anxiety levels and improved marital adjustment and satisfaction, helping to improve the lives of the couples involved.


Field et al (2008) Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationship.

Journal of Bodywork and Movement Therapies 12, 146-150

This was a study using 47 prenatally depressed women who received twice weekly massages from their partners for 20 weeks up to time of delivery. A control group was used in the study and the women were randomly assigned to either the experimental or the control group. Self reported leg and back pain, depression, anxiety and anger decreased in the experimental group. Data showed that not only the women had improved mood, but their partners reported improvement in mood and were less anxious as well. Overall relationships seemed to improve between the women and their partners.


Field et al (2007) Lower back pain and sleep disturbance are reduced following massage therapy. Journal of Body and Movement Therapies, 11, 156 - 160.

The study involved 30 adults with low back pain endured for at least 6 weeks. Massage treatments were given for 30 minutes twice a week for 5 weeks to the experimental group. On the first and last days of treatment the participants were assessed for range of movement in the lower back and asked to complete a questionnaire about their experiences of pain, anxiety and sleep patterns. By the end of the study the massage treatment group showed improvement in range of movement tin the lower back, and felt less pain and anxiety and were able to sleep better.


Billhult A. Maatta S. ( 2009) Light pressure massage for patients with severe anxiety. Complementary Therapies in Clinical Practice 15, 96-101

The study describes the experience of receiving massage for patients with generalised anxiety disorder. Findings showed that the patients were able to find their own capacity during the massage period. Their experiences were about being relaxed in mind and body and having unconditional attention, feeling less anxious and more self-confident. There are clinical implications for the use of massage when immediate pain and anxiety relief is required. Available interventions for anxiety are often pharmacological or psychotherapeutic and often have delayed results. Massage can be used to complement treatments when immediate relief is desirable.


Research Studies and evidence-based literature

The following abstracts and references are intended to give members a brief outline of the current developments and findings in Massage and the world of Complementary Medicine. The list does not include all the literature available on the subject of massage but does give a flavour of what is happening in the research world. It is intended to help members consider how research and evidence may influence practice.

Pauline Stuttard CPD Committee Member

This was a study using 47 prenatally depressed women who received twice weekly massages from their partners for 20 weeks up to time of delivery. A control group was used in the study and the women were randomly assigned to either the experimental or the control group. Self reported leg and back pain, depression, anxiety and anger decreased in the experimental group. Data showed that not only the women had improved mood, but their partners reported improvement in mood and were less anxious as well. Overall relationships seemed to improve between the women and their partners.

Eisensmith L.P ( 2007) Massage therapy decreases frequency and intensity of symptoms relating to temporomandibular joint syndrome in one case study.

Journal of Bodywork and Movement Therapies 11, 223-230

The study investigated the ability of massage therapy to mitigate the frequency and intensity of headaches, jaw clicking and masticatory pain associated with temporo-mandibular joint syndrome (TMJ) The study was done with one client, a 22 year old officer in the armed forces. Massage techniques combined with strain and counterstrain techniques were administered for 30 minutes twice a week over a 3 week period. Results showed that intensity and frequency of pain in the jaw decreased and jaw opening increased by a third.


Kalamir et al ( 2007) Manual therapy for temporo-mandibular disorder: a review of the literature Journal of Bodywork and Movement therapies 11, 84-90

This review of published materials and studies regarding treatments of TMJ dysfunction includes massage, electrotherapy and manipulative therapy. The review comments that all 3 therapies are viable and cost effective in the treatment of TMJ compared to other forms of treatment. It is likely that these forms of treatment will become more popular in the future due to their cost effective nature.


Billhult A. Maatta S. ( 2009) Light pressure massage for patients with severe anxiety Complementary Therapies in Clinical Practice 15, 96-101

The study describes the experience of receiving massage for patients with generalised anxiety disorder. Findings showed that the patients were able to find their own capacity during the massage period. Their experiences were about being relaxed in mind and body and having unconditional attention, feeling less anxious and more self confident. There are clinical implications for the use of massage when immediate pain and anxiety relief is required. Available interventions for anxiety are often pharmacological or psychotherapeutic and often have delayed results. Massage can be used to complement treatments when immediate relief is desirable.


Fraser J. Kerr J.R. ( 1993) Psychophysiological effects of back massage on elderly institutionalized patients. Journal of advanced nursing 18, 238-245

An experimental design was used to measure the effects of back massage on anxiety levels of residents in a long term institution. 21 Subjects were randomly assigned to three groups which received either back massage with normal conversation, conversation only or no intervention. The dependent variable, anxiety was measured prior to back massage and immediately and 10 minutes following treatment. The difference between the back massage group and the conversation group reached statistical significance. Results showed that back massage was an effective non invasive technique for promoting relaxation and improving communication.


Professional Issues and Culture

Stone J. (2008) Respecting professional Boundaries: What CAM practitioners need to know. Complementary Therapies in Clinical Practice 14, 2-7

Professional boundaries are central to professionalism. Failure to maintain sexual and emotional boundaries can cause significant and enduring harm. Evidence from complaints shows that boundary abuses do occur. Concerns are heightened by context, regulatory and therapeutic aspects of relationships in CAM. The article argues that sexual boundaries should be a specific element of training and makes recommendations about patient safety.


Moyer C. A. Rounds J. ( 2009) the attitudes towards massage ( ATOM) scale: Reliability, validity and associated findings Journal of Bodywork and Movement Therapies 13,22-33

The authors discuss development of an attitude towards massage scale (ATOM), a nine item measure of overall attitude to ‘massage as helpful’ and ‘massage as pleasant’. The scale has been developed as an easily administered measure for assessing patient attitude towards massage that can be used in research or practice settings.


Massage and Back Pain

Field et al ( 2007) Lower back pain and sleep disturbance are reduced following massage therapy

Journal of Bodywork and Movement Therapy 11, 23-32

A randomized between groups design was used to evaluate massage therapy versus relaxation therapy for chronic back pain. Treatment effects were evaluated for reducing pain, depression, anxiety and sleep disturbance. Treatment was also analysed for improving trunk range of motion and reducing job absenteeism. 30 adults suffering low back pain for 6 months participated in the study. The groups did not differ on age, socio-economic status, ethnicity or gender. The massage group received a 30 minute back massage twice a week for 5 weeks and both groups completed a questionnaire on the first and last days of treatment as well as an assessment for range of movement. By the end of treatment the massage group reported experiencing less pain, depression and anxiety and consequently slept better. They showed an improvement in trunk flexion.


Budh C.N. Lundberg T ( 2004) Non pharmacological pain relieving therapies in individuals with spinal cord injury: a patient perspective

Complementary Therapies in Medicine Dec 2004 vol 4 189-197

123 patients with spinal cord injury were assessed in a spinal unit in Stockholm 1999 and followed up in a mailed survey 3 years later. 63% of the patients had tried non-pharmacological treatments such as acupuncture, massage and transcutaneous nerve stimulation (TENS). Massage and heat were the treatments reported to result in the best pain alleviation.


Ernst E. (1999) Massage therapy for low back pain: a systematic review

Journal of pain and symptom management 1999 17 (1) 65-9

Massage therapy is frequently used for low back pain. The aim of the systematic review was to find evidence for or against its efficacy. Randomised trials were located in which massage was tested as a monotherapy. All were burdened with methodological flaws. One study suggested that massage is better than no treatment and 2 suggest that it is equally effective to spinal manipulation or TENS. Too few trials exist for reliable evaluation of efficacy in massage, but it does seem to have potential as a therapy. More investigation of the subject is urgently needed.


Preyde M (2000) Effectiveness of massage therapy for subacute low back pain: a randomized controlled trial.

Canadian Medical Association Journal Jun 27 162 (13) 1815-20

107 Subjects were randomly assigned to 1 of 4 groups. Comprehensive massage therapy, soft tissue manipulation, remedial exercise or a placebo. They received 6 treatments over a month. The comprehensive massage group had improved function and less intense pain compared with the other 3 groups. At 1 month follow up 63% of the subjects in the massage group reported no pain, compared with 23% of the soft tissue group, 14% of the remedial exercise group, and 0% of the placebo group.