We are a nation of people living with chronic, acute or long-term pain, and research is bearing out the hope that massage therapy can play an important role in pain relief for a variety of populations — while providing an alternative to opioids.
This was the message out of Alexandria, Virginia, where about 300 people, primarily massage therapists, converged on the Massage Therapy Foundation’s (MTF) International Massage Therapy Research Conference, May 9–10.
At this moment, many government entities, including the Department of Defense (DoD), Veterans Administration (VA) and National Institutes of Health, are studying such therapies as massage, stretching and meditation.
Driven in large part by researchers and those in the medical profession intent on finding alternatives to opioids, this focus on pain is magnified right now, as is the scrutiny of integrative therapies and the opportunity for massage therapists to support research and advocate for the inclusion of massage in medical systems.
MTF President Douglas Nelson, LMT, said that earlier in his 42-year massage career he could not have imagined this moment.
Addressing the conference audience, Nelson said, “We need to seize that moment and we need to act now.
“There is no force on the planet more powerful than unity of purpose, and when I sit back and see all of you, I think about unity of purpose,” he said. “The world needs the good work that we do now, more than ever before.”
What follows is a recap of some of the conference presentations, feedback from therapists who attended, and links to sources of further information.
Massage & Arthritis
The statistics related to arthritis are sobering, said researcher Nicole Nelson, MSH, LMT, an adjunct instructor in the department of exercise science at the University of North Florida. One in four American adults have arthritis — a figure that could grow as obesity, a primary risk factor for osteoarthritis, expands as well — she said.
As the arthritis problem progresses, massage therapy is gaining attention as a therapeutic approach to managing both osteoarthritis and rheumatoid arthritis symptoms.
Conference attendee Dorothea Atkins, ThD., RN, LMT, who practices in Haddon Heights, New Jersey, said she was inspired by the potential of massage to address joint problems like arthritis.
“Self-massage of the hands and knee was mentioned as an on-demand method to manage joint pain, promote relaxation and reduce anxiety,” she said. “Why not educate our clients with nonpharmacological self-care options based on the research? A new option for an old problem, chronic joint pain.”
Nelson said the effect of massage therapy on arthritis is promising but not yet fully understood.
“Maybe massage’s effectiveness depends on the main driver of the person’s pain,” she said. “Are they feeling pain because of their joints, or because they’ve had that chronic disorder for 10 years and now their nervous system has changed because of the disease process?
“Because pain is so complex, we should start investigating key drivers of a person’s pain experience,” Nelson added.
For more information, read Nelson’s review, “Massage Therapy for Pain and Function in Patients with Arthritis: A Systematic Review of RCTs.” (Published in the American Journal of Physical Medicine & Rehabilitation, 2017; 36(5) 665-673.)
Massage & Pain
Director of the National Center for Complementary and Integrative Health (NCCIH) Helene Langevine, MD, discussed the prevalence of pain and how people in pain modify how they move in response to pain, which can further exacerbate pain.
“In people who have restricted movement and imbalances of muscles and connective tissue thickening, over time this causes an abnormal load distribution throughout the whole body — and this can damage structures like joints,” Langevine said. “They can start developing arthritis, degenerative discs, et cetera. How can we prevent this from happening?”
She said connective tissue remodeling is reversible to a great extent, and muscles can be retrained. “The whole system is plastic, and that’s great, really great.” The body can repair, regenerate and restore function — but, she added, “We want to intervene early, before patients need something like surgery.”
For more information on the role of the NCCIH, watch this video featuring Langvine.
Hunter Groninger, MD, spoke on integrating massage therapy for hospitalized palliative care patients. He practices at MedStar Washington Hospital Center in Washington, DC.
Medstar is in clinical and research partnership with healwell, which provides highly trained massage therapists to clinical partnerships at seven facilities in the DC Metro area to provide massage for patients with advanced illness, as part of the hospital’s trans-disciplinary model.
The people who receive care in this model are suffering from such diseases and conditions as progressive heart disease, stroke, heart failure, lung disease, HIV or stroke. They will die relatively soon or are actively dying and are living in what Groninger termed “total pain,” on physical, spiritual, social and emotional levels. He explained these levels further:
• Physical pain causes variable degrees of distress, interferes with other aspects of life and usually needs treatment via drugs.
• Spiritual pain may include feelings of guilt or remorse, and fear of death.
• Social pain might look like feeling distress over family members, a sense of loss of one’s life roles and ability to participate in life.
• Emotional pain might include adjustment disorders, anxiety and depression, frustration and hopelessness.
“If our goal is to support these patients and family, if our goal is to relieve their suffering, we must think beyond physical pain,” Groninger said.
The team includes an MD, nurses, social workers, a pharmacist, spiritual care and massage therapists. Groninger said he will call healwell’s founder, Lauren Cates, LMT, and ask her to see a patient, and she will report back her recommendations for whom the patient should see next. That type of teamwork “generates a larger conversation about the patient,” Groninger said.
“One thing that I’ve learned from Lauren Cates is that massage can be a conversation with the nervous system,” he said, adding that it isn’t something the therapist is doing to the patient, but something the therapist and patient do together.
In a Medstar study, patients who received massage had a significantly improved pain score 24 hours later.
Other study results being analyzed now relate to a dosing study that compared one 10-minute massage given on three days, one 20-minute massage given on three days and one 20-minute massage given on one day. Groninger expressed happiness that 76% of the patient population in this study is African American, because, he said, most research studies in integrative care look at Caucasian people with a middle-to-high socioeconomic status.
With the trans-disciplinary approach, Groninger said, “We are thinking about [pain] in a different way; we are thinking beyond opioids that target just physical pain.”
Massage & Opioids
The overall medical response to chronic and acute pain has been to write prescriptions, oftentimes for opioids. The resulting well-documented opioid epidemic has resulted in 42,000 overdose deaths in one year, 2016, alone, according to the National Institute on Drug Abuse.
This epidemic hasn’t shown signs of slowing down, experts say, which is one reason alternative approaches to pain relief are getting a lot of attention from government entities.
Experts who have been deeply involved in research on therapies to combat pain presented information about studies on non-pharmacological alternatives, including massage, for pain relief.
In 2016, 20.4% (50 million) of U.S. adults experienced chronic pain and 8% had high-impact chronic pain, according to Robert D. Kerns, PhD, program director of the National Institutes of Health-Department of Defense-Department of Veterans Affairs Pain Management Collaboratory. His presentation was titled “Addressing the Opioid Epidemic with Massage Therapy.”
The people most susceptible to chronic and high-impact chronic pain are women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance and rural residents, according to Kerns.
The cost of pain is estimated at $500 to $635 billion a year, and pain conditions — which include irritable bowel syndrome, endometriosis, fibromyalgia, chronic migraine, chronic low-back pain, chronic fatigue syndrome, tension-type headache and temporo mandibular disorders, among others — cost more than cancer, heart disease and heart conditions combined.
“It’s important that we look around the room, and it may well be that at least 20 percent of the people in this room, maybe higher, have chronic pain,” said Kerns. “Yet here you are participating in your profession and travelling to conferences,” he added, indicating that we might not always realize that such a large percentage of people suffer from chronic pain.
The opioid epidemic isn’t just about the over-prescription of pain-relieving opioid medication; it’s also about patients getting hooked on those drugs and then, when they can’t get prescription refills, in some cases turning to heroin or fentanyl, said Kerns.
“Eighty percent of people who use heroin first misused prescription opioids,” said Kerns, adding that 8% to 12% of people who use opioids develop an opioid use disorder. Pointing to a projected slide, Kerns said opioids are causing tragedy, overdose and deaths.
“Over the last two decades in particular there has been an escalation in terms of harms,” he said. “Unfortunately, we continue that for the next year or two beyond this slide [which was dated 2016], [and] the rates of harm have continued to escalate despite public knowledge and public policy related to this crisis.”
He said although there are multiple kinds of opioids, including fentanyl and heroin —prescription opioids in the form of therapeutic use continue to be “an important driver” of this epidemic.
Even as the opioid epidemic steams ahead, clinicians are overseeing trials being enacted in real-world settings to study approaches including massage, chiropractic, yoga, mind-body therapies and more, Kerns said.
Many such trials are taking place at VA and DoD health systems locations. Veterans, especially, provide a population of subjects who experience comorbidities, said Kerns.
In 340 veterans who served in era of Afghan and Iraq wars, for example, he said, “There were very few people who had symptoms of [traumatic brain injury] without the presence of PTSD or pain, in fact, the largest majority had clinical diagnosis conditions of pain, PTSD and traumatic brain injury (TBI).”
He said mood disorders, substance use disorders, depression and anxiety also go along with high pain rates.
“So, we need to look at the person with pain rather than just the pain,” Kerns said.
Lt. Gen. (RET) Eric Schoomaker, MD, PhD, of the Uniformed Services University of the Health Sciences, and Heather Tick, MD, University of Washington and lead author on the December 2017 white paper, “Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper,” also presented on massage and opioids.
“Lt. Gen. (RET) Eric Schoomaker, MD, PhD, emphasized that this research has been public for over a decade, but the challenge has been enacting a model of care that incorporates the findings of these scientific and research studies into clinical practice,” said Greg “Rhino” Ragni, LMT, CPT, and his wife, Carrie FitzGibbon, a Reiki master, who practice in Bethlehem, Pennsylvania, and attended the conference together. They provided a quote about their experience to MASSAGE Magazine via email. “It has been our personal experience that a multi-modal, therapeutic approach can be extraordinarily effective in relieving musculoskeletal pain and injury.
“Having had difficulty finding this kind of multi-disciplinary model ourselves, we decided to create one,” Ragni and FitzGibbon added. “We are pleased to discover that current scientific research validates this plan of care.”
How You Can Seize This Moment
“In my 13 years as an LMT, I’ve attended many conferences and CE classes throughout the country — without a doubt, the [International Massage Therapy Research Conference] is my favorite conference due to the amazing content and inspirational speakers,” said Corrie Frey, LMT, CIMI, CPMT, a massage therapist in the Massage Therapy Department, Division of Clinical Therapies at Nationwide Children’s Hospital in Columbus, Ohio. Frey presented a research poster at this year’s conference, and previously.
“Both times that I have attended the IMTRC, I’ve walked away with a renewed excitement for the massage profession and how I can contribute to moving it forward in continuing to gain more evidence and confirmation that our work has benefits beyond measure,” she said.
The next MTF International Massage Therapy Research Conference will be held in 2022. Until then, the MTF has various ways massage therapists can volunteer to support research on massage therapy.
There are additional ways you, as a massage therapist, can be part of the shift toward holistic therapies as a means of addressing pain. According to Kerns, advocacy on this front needs to happen on a local, regional and national level.
Explore, read and become knowledgeable about the shift toward holistic therapies happening now, to determine if opportunities for you exist in it and to be more educated when talking to clients and networking with medical professionals.
Those include:
The NIH-DoD-VA Pain Management Collaboratory
The Federal Pain Research Strategy
The National Pain Strategy
The CDC Guideline for Prescribing Opioids
“I’d encourage you to take advantage of opportunities to network in your community and speak about what you’re doing and the importance of what you’re doing and really speak to the evidence and with a message that will be attractive to people,” said Kerns. “If there are the opportunities to get involved in advocacy efforts, do that.”
About the Author
Karen Menehan is MASSAGE Magazine‘s editor in chief.