Research into the effects of massage has been largely behind the increased use of massage and its incorporation into medical environments. Here, experts in the field of massage research discuss the importance of research literacy on the part of massage practitioners, how research advances massage in the medical arena, the purpose of mechanism studies, how massage research has grown over the last decade—and what needs to be done to further research in years to come.
A Decade of Growth
by Diana Thompson and Albert Moraska, Ph.D.
A decade ago there was very little research conducted into massage therapy. In part, this was because there was little financial or infrastructural support. Much has changed in the past 10 years.
In addition to the Massage Therapy Foundation increasing research funding in massage over the past 10 years, the National Institutes of Health (NIH) established the National Center for Complementary and Alternative Medicine (NCCAM) in 1999. NCCAM was founded to study complementary and alternative medicine (CAM) and was given a base of $50 million. Today, NCCAM is funded at more than $121 million annually and is funding more studies that include massage than ever before.
Other organizations, such as the Massage Therapy Research Consortium, have been formed to involve massage-therapy schools in research by creating a collaborative environment and pooling resources to advance massage-therapy education and practice. In addition, the Touch Research Institutes at the University of Miami School of Medicine continues its research into massage for various medical conditions.
We also now have more avenues to disseminate research findings: Peer-reviewed journals focus on massage or bodywork topics; research conferences, such as the Fascia Research Congress; Highlighting Massage Therapy in CAM Research; and the North American Research Conference on Complementary and Integrative Medicine are now held regularly and provide a means for researchers and practitioners to interact and share experiences.
In just a few years, there have been big changes for research in massage.
Facing the future
The previous five to 10 years were instrumental in getting research in massage and bodywork therapies launched, and if the next five to 10 years can be as successful, that would be very impressive. But to address this, we need to look at it from the perspective of the researcher and the practitioner, which are not necessarily separate entities.
From the research side, we need to strengthen what has been accomplished. For example, while the NIH funds research in complementary and alternative medicine at $121 million per year, only a small fraction of that goes to research in bodywork therapies. While there are multiple conferences where research can be presented and ideas exchanged, these occur bi- or tri-annually, which causes continuity to be lost. And while there are at least two peer-reviewed research journals aimed at bodywork, they are in their infancy and don’t yet have a large readership. Building on what has been accomplished, so there is no backsliding, is important in the short term.
From the practitioner side, greater communication to the research community is needed. In 1993, David Eisenberg and colleagues published a seminal report noting the magnitude of use of CAM therapies. This report helped spawn the drive for research into CAM.
Additional issues to address might be: For what types of ailments are people seeking massage? Are they experiencing improvement? Practitioners are the first line for recognizing the effects of their work, and this information needs to be transferred back to the research community. Practitioners and researchers are currently working toward improved communication, but difficulty still exists.
For most practitioners, there isn’t a local neighborhood massage researcher they can discuss an idea or clinical finding with, so they may lack a receptive ear for sharing their experiences. Fortunately, there are now several outlets for publishing a case report (go to www.google.com and input “massage case report” to find these outlets), which is a perfect medium for this type of communication.
Case reports’ importance
Case reports lay the foundation for research by telling the stories of who we are, who our clients are, how we work and how we impact our clients’ health or their experience of health and well-being.
When we see something of significance occur in our clinical practices—something we are excited about—we should share these experiences or findings with others, even if it simply involves telling the commonplace story. There is no cache of case reports that tell our stories, so by sharing these experiences, we can forward the field.
A case report can also help identify new hypotheses by presenting an instance where a particular treatment resulted in an interesting effect. Even though the case report is only based on one client, it can provide insight into a particular ailment or type of treatment that may be further studied by other researchers.
Advancing massage
Research is a key component of the professional reputation of any field. There are two broad categories of research: clinical studies and basic research.
Clinical studies help identify what is beneficial at the whole body level. In contrast, basic research is trying to gain a mechanistic understanding. Both of these arenas are important because we need to understand what works and what doesn’t at the human level and use basic science to validate, in an objective way, the effect of a treatment.
In order to gain acceptance by the medical profession, and thus increase massage’s use as a therapeutic modality, a thorough understanding of what conditions it benefits and the mechanism of how it works is necessary. Published research validates the use of massage to medical professionals who might otherwise be skeptical regarding its benefits and default to treatment forms they are more familiar with.
What works? Why?
Every therapist we have ever met has an insatiable desire to serve her clients as best she can. Inherent in that is a curiosity to uncover what works and why. The roadblocks massage therapists often face are in locating the research literature and then making sense of it, so they can take advantage of research findings in their sessions.
We see the job of the Massage Therapy Foundation and of massage schools as one of encouraging practitioners to ask questions and assist them in finding the answers in the research, rather than answering the questions for them. The answers will change as we discover more about how massage works. Providing answers that are quickly outdated is not useful. Research literacy exemplifies the adage, “teach them how to fish and they will never go hungry.”
How you can be involved
Write case reports, attend research conferences and get involved in discussion groups or networking events. Writing a case report is one of the best ways to directly contribute to the research base and can have a bigger impact than one often thinks.
Also, becoming more research literate will help one understand where one’s own experiences fit in with or add to what is currently known and will help the presentation of findings become more accepted by discussion groups or those reading scientific publications. Did we mention writing up your findings in a case report? They really are a terrific way to get involved in research.
What research tells us
The only thing definitive at this point is a large percentage of the general public seeks massage therapy for many reasons, including relaxation, stress reduction and relief from musculoskeletal pain. We still don’t have definitive evidence there is a clinical effect—but this should not be surprising at this point, given the limited depth and breadth of research in the field at the present time.
What does research tell us about the mechanisms of massage? Again, this is an area still very primitive in our understanding. There are a lot of hypotheses on a mechanism for massage, such as it reduces the stress hormone cortisol or increases blood flow, but the published research, when taken as a whole, is conflicting and not that well conducted. Better conducted studies on a mechanism for massage would help convince those who are skeptical and go a long way toward swaying the naysayers that there can be more to massage than it simply feels good.
Diana L. Thompson is president of the Massage Therapy Foundation. She is a licensed massage practitioner in the state of Washington. She began her practice in Iowa in 1979, working exclusively with college athletes, and became licensed in Washington in 1984 where she founded Lakeside Massage-The Injury Clinic. Her book Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists was published in 1993, and the third edition was published in 2005.
Albert Moraska, Ph.D., serves on the board of trustees for the Massage Therapy Foundation. He is interested in research associated with massage therapy and has conducted studies involving massage and headache, carpal tunnel syndrome and sports massage. He recently served as director of clinical research at the Boulder College of Massage Therapy and is currently an assistant professor at the University of Colorado Health Sciences Center. He received his doctorate in Integrative Physiology.
Research Literacy is a Critical Skill for Practitioners
by Martha Menard, Ph.D.
I believe research literacy—the ability to critically evaluate the information presented in health-care research journal articles—is a necessary skill for every practitioner. I graduated from the Potomac Massage Training Institute in 1982 and have practiced massage therapy in a variety of settings over the past 26 years, from hospitals to spas to private practice. My experience is massage clients with chronic illness or other serious health-care concerns are encountered in every setting. Since I completed my doctoral degree, I have worked as a teacher and author to help other practitioners develop their research literacy and capacity skills.
Why do I think research literacy is so important? The landscape of health care has changed dramatically over the past two decades. Complementary therapies, such as massage, are increasingly accepted by the public and are starting to be integrated into conventional medical care. At the same time, both conventional and complementary interventions are now being held to a new standard: an evidence base of research to justify and support their use by consumers, a movement known as evidence-based health care.
Massage therapy has risen to this challenge with a growing body of evidence that supports its practice, and more research is currently in development. But all this scientific effort is wasted if massage therapists do not use the existing information available to them to inform their clinical work, to translate research into practice.
I strongly believe research literacy is vital to the continued development of our profession, for several reasons:
1. It is a valuable skill that allows massage therapists to use research findings to improve the quality of care offered to clients in any setting.
2. It gives us confidence in speaking to and working with clients with a wide range of health issues, and it provides a common language and shared frame of reference for communicating with other health-care providers.
3. It can be an avenue for continuing education.
4. It is a necessary step in developing research capacity, the ability to design and conduct original research.
Additionally, I have used my research literacy skills on behalf of family and friends faced with serious illness, identifying relevant articles for them to discuss with their physicians and helping ensure they received the best possible care
Although some practitioners may feel intimidated by the thought of critically reading a health-care research article, I like to think of research literacy as a form of applied common sense, which is the approach I take as a teacher.
Research helps us separate what works from what doesn’t. Reading research can inform our clinical decision-making skills and our choices among available approaches to working with clients—and it helps us all to be better therapists.
Martha Brown Menard, C.M.T., Ph.D., is the author of the massage textbook, Making Sense of Research, a guide to research literacy for the nonscientist. A former member of the board of trustees for the Massage Therapy Foundation and chair of the foundation’s research grant review committee, she currently holds a research faculty appointment at the University of Virginia School of Medicine. She maintains a private practice in Charlottesville, Virginia, specializing in oncology massage, and is a founding member of the Society for Oncology Massage.
How Research Advances Massage in the Medical Arena
by Whitney Lowe
In the early years of my massage career, I used to spend my spare time in the medical library at Emory University in Atlanta, Georgia. I felt like a kid in a candy store every time I went in there, awestruck at the wealth of fascinating information about the body housed within those walls. It was that time spent in the medical library in those years that began my great appreciation for the value of research and how it greatly enhanced my massage practice.
I was working at an orthopedic clinic at this same time and soon realized my physician and physical therapist colleagues were developing new and innovative treatment techniques directly out of what they learned from recently published research studies. I recognized reading research material could affect my massage practice in the same way and lead me to become a much better therapist and more able to help people in pain.
In my early years, very little research was designed to specifically study the effects of massage therapy. Yet, I found all kinds of valuable information in research studies in the fields of physical medicine, orthopedics, biomechanics, sports medicine, psychology and rehabilitation science that greatly shaped, and in some cases radically changed, my views of how to achieve the best results with clinical massage.
Here were numerous instances when I had been teaching and practicing a certain approach or technique for years and then came across an issue in research papers that radically shook my perspective and forced me to rethink the way I approached a clinical problem. Incorporating those new concepts made me more successful in the clinic and had a direct effect on the success of my business and the respect given to me by my health-care colleagues.
As a massage teacher, reading research in all these fields helped me become a much better educator because I understood so much more about what I was teaching in the classroom instead of just mimicking what other teachers had previously told me before. Reading research helped me develop an inquisitive mind and constantly search for an understanding of why I did the things I did in the clinic room. I certainly wouldn’t expect everyone to have the same degree of excitement I feel about reading and studying research, but I think it is a very powerful engine that drives innovation and improvement of our profession and helps us all become much more skilled practitioners.
Whitney Lowe is a recognized authority on pain and injury treatment with massage therapy. His contributions to the massage field include research, professional publications, teaching, clinical work and consulting. He is the author of the books, Orthopedic Assessment in Massage Therapy and Orthopedic Massage: Theory and Technique.
Why We Need Mechanism Studies in Massage Therapy
by Trish Dryden
There is growing research evidence that therapeutic massage is a useful modality for relieving a variety of musculoskeletal symptoms, such as pain and function,1, 2, 3, 4 and that massage can also positively affect mood state5 and pain threshold6. But the mechanisms, or the underlying physiological reasons, by which massage exerts therapeutic effects are not understood.
Some studies indicate soft-tissue manipulation is associated with local changes in blood flow and oxygenation7. Soft-tissue manipulation may influence neural activity peripherally, at the spinal cord segmental level, and centrally by modulating the activities of subcortical autonomic nuclei that influence mood and pain perception8.
In addition, massage at body locations remote from painful areas may also modulate pain perception through effects on central nervous system activity.
Mechanistic studies are necessary to understanding underlying biological and psychological effects of massage and their relationship to outcomes.
Currently, a pilot research study, funded by the Holistic Research Foundation of Canada, “Influence of Therapeutic Massage on the Physiology and Metabolism of Muscle and the Central Nervous System: Evaluation by Magnetic Resonance Spectroscopy (MRS) and Functional Magnetic Resonance Imaging (fMRI) in Healthy Subjects and Subjects with Subacute Low Back Pain,” is under way as a collaboration between the Brain-Body Institute, Imaging Research Centre at St. Joseph’s Healthcare Centre and Centennial College in Ontario, Canada9.
The study objectives are:
1. Using noninvasive imaging techniques to determine whether Swedish-type therapeutic massage influences local musculoskeletal physiology and distant subcortical brain physiology in healthy subjects and subjects suffering from low-back pain.
2. Using validated questionnaires to examine the effect of massage on pain and mood state.
The study methods are as follows: prior to the 30-minute back-massage intervention, psychosomatic assessments using validated pain scale and mood questionnaires will be administered. Magnetic resonance spectroscopy (MRS) and fMRI of the low-back muscles will also be performed and followed by an fMRI of the brain to evaluate subcortical effects. Baseline resting state BOLD imaging will be used to look for variations in blood flow and oxygenation. Having obtained the baseline data, a structured half-hour Swedish massage will be administered to the eight pilot study subjects. The same evaluations will be repeated following completion of the massage, and the pre- and post-massage imaging will be compared.
The research team hypothesizes the mechanism(s) underlying the therapeutic components of massage may be twofold: First, a rapid, direct effect on local fascia, muscle and nerves; second, a slower, delayed effect on the subcortical central nervous system that ultimately incorporates remodeling of plastic neuronal connections.10, 11
We hope this testable model will open up new research avenues that link objective physiologic indices with the effects of massage on the subjective experience of pain and other symptoms.
Footnotes
1. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2002 Sept. 1;27(17):1896-910.
2. Tsao J. (2007) Effectiveness of massage therapy for chronic, non-malignant pain: A review. eCAM Advance Access published online on Feb. 5, 2007.
3. Cherkin D, Sherman K, Deyo R, Shekelle P. (2003). A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine, 138(11):898-906.
4. Preyde M. (2000) Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Can. Med. Assoc. 162: 1815 – 1820.
5. Moyer C, Rounds J, Hannum J. A meta-analysis of massage therapy research. Psychol Bull. 2004; 130(1):3-18.
6. Lund I, Yu L-C, Uvnas-Moberg K, Wang J, Yu C, Kurosawa M, et al. Repeated massage-like stimulation induces long-term effects on nociception: contribution of oxytocinergic mechanisms. European Journal of Neuroscience 2002; 16:330-8.
7. Mori H, Ohsawa H, Tanak TH, et al. Effect of massage on blood flow and muscle fatigue following isometric lumbar exercise. Med Sci Monit; 2004; 10:173-178.
8. Melzack R. Pain and the neuromatrix in the brain. J Dent Educ 2001; 65:1378-82.
9. Research team: Dryden T, Noseworthy M, Sagar S, Wong R – contact tdryden@centennialcollege.ca for further information.
10. Sagar S, Dryden T, Myers, C. (2007). Research on therapeutic massage for cancer patients: Potential biological mechanisms. Journal for the Society of Integrative Oncology, 5(4), 155-161.
11. Sagar S, Dryden T, Wong R. (2006). Massage therapy for cancer patients: a reciprocal relationship between body and mind. Current Oncology [Online] 14:2. Available: http://www.current-oncology.com/index.php/oncology/article/view/139/105.
Trish Dryden, R.M.T., M.ED., is director of applied research and innovation at Centennial College in Toronto, Ontario, Canada. As a researcher, clinician and educator, Dryden is an internationally recognized leader in massage therapy research and in interprofessional education and evaluation. She is the winner of the American Massage Therapy Association’s President’s Award for 2008.
Make Responsible Claims About Massage
by Tracy Walton
As a profession, we need to use research results cautiously and make more responsible claims about research. We are tempted to claim, “Research proves massage helps with X” whenever a study is published in that area. In fact, most massage studies are small, and typically there is only one study, or a handful, on a single topic. This is not enough to claim proof, nor is it even enough to make a strong statement, such as, “Research benefits ‘Y,’” or “Research shows massage helps with Z.” All of these statements are too strong, when they are trumpeting a single study.
I don’t mean to diminish the contributions of any researcher—I know from experience research on massage can be difficult, and each study in massage therapy is an accomplishment. Good research, even if it is small in size, should be celebrated, analyzed, scrutinized and welcomed into the growing pool of information about our work. But evidence-based medicine uses a body of strong research to support a claim, not a single, small study. We need to honor this same standard.
The gold standard in research is the meta-analysis, an independent, quantitative review of the available studies. Using careful statistical methods, a reviewer treats a pool of smaller studies as one large one, and more reliable conclusions can be drawn from that careful, peer-reviewed process than from a smattering of small studies. A great source of these reviews, on a range of therapies, is the Cochrane collaborative at www.cochrane.org/. Do a search on massage therapy and find several quantitative reviews, with summaries in plain English.
While remaining on the lookout for these larger works, we have to be careful not to overstate the results from smaller studies. When I present research results on massage and cancer, I stick to sturdier, more modest statements, such as, “The body of research in this area is small, but growing. Of the available studies, the strongest support is for help with anxiety,” or something similar. Most of the time, it’s more accurate to use “Research suggests … ” rather than “Research proves … ”
Each time we come across a study, before repeating its claim, we need to look at whether other researchers have found similar results. Look for a meta-analysis or some kind of review on the topic. This “thinking pause” goes a long way and serves our profession best in the end.
Tracy Walton, L.M.T., consults to hospitals and massage schools, writes and teaches Caring for Clients with Cancer for massage therapists. She offers a bibliography of cancer and massage research on her Web site, www.tracywalton.com. She is at work on a textbook, Medical Conditions in Massage Therapy.